Provider Demographics
NPI:1447667217
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: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 1:1250 E 3900 S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1348
Mailing Address - Country:US
Mailing Address - Phone:801-268-6283
Mailing Address - Fax:801-263-3579
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-268-6283
Practice Address - Fax:801-263-3579
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT050912261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
000004880Medicare UPIN