Provider Demographics
NPI:1881797876
Name:GRANGER MEDICAL CLINIC INC
Entity type:Organization
Organization Name:GRANGER MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-965-3417
Mailing Address - Street 1:12391 S 4000 W
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7012
Mailing Address - Country:US
Mailing Address - Phone:801-302-1700
Mailing Address - Fax:801-302-1714
Practice Address - Street 1:12391 S 4000 W
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7012
Practice Address - Country:US
Practice Address - Phone:801-302-1700
Practice Address - Fax:801-302-1714
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-06
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004880Medicare PIN
UT0977270002Medicare NSC