Provider Demographics
NPI:1982804050
Name:ROBERT P. GRANACHER, JR. MD, PSC
Entity Type:Organization
Organization Name:ROBERT P. GRANACHER, JR. MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANACHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:859-277-5213
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE A-400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-277-5213
Mailing Address - Fax:859-277-5413
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE A-400
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-277-5213
Practice Address - Fax:859-277-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16988174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64169881Medicaid
KY64169881Medicaid
KY11833Medicare PIN