Provider Demographics
NPI:1952367039
Name:GRANUM, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GRANUM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:940 E 3RD ST
Mailing Address - Street 2:#205
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3237
Mailing Address - Country:US
Mailing Address - Phone:307-577-4260
Mailing Address - Fax:307-577-4263
Practice Address - Street 1:940 E 3RD ST
Practice Address - Street 2:#205
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3237
Practice Address - Country:US
Practice Address - Phone:307-577-4260
Practice Address - Fax:307-577-4263
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WY3007A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYF39253Medicare UPIN