Provider Demographics
NPI:1932216652
Name:GRANGER MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:GRANGER MEDICAL CLINIC, PC
Other - Org Name:GRANGER MEDICAL CLINIC - MILLCREEK ALLERGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3505
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:SUITE #C130
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-281-1300
Mailing Address - Fax:
Practice Address - Street 1:1121 E 3900 S
Practice Address - Street 2:SUITE #C130
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1214
Practice Address - Country:US
Practice Address - Phone:801-281-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-25
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1773041205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07742Medicare UPIN
UT000057922Medicare PIN
UT000004880Medicare PIN