Provider Demographics
NPI:1962580589
Name:GRANICH, RUSS D (MD)
Entity type:Individual
Prefix:DR
First Name:RUSS
Middle Name:D
Last Name:GRANICH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2927
Mailing Address - Country:US
Mailing Address - Phone:510-928-5848
Mailing Address - Fax:
Practice Address - Street 1:659 TOWER AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1259
Practice Address - Country:US
Practice Address - Phone:860-763-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50400207QG0300X, 207QH0002X, 207R00000X
CT067712207R00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G504000Medicaid
CA00G504000Medicaid
A51668Medicare UPIN