Basic Information
| Provider Information | |||||||||
| NPI: | 1104567882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANGER MEDICAL SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7181 S CAMPUS VIEW DR STE 200 | ||||||||
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| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840844312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019653505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | MARY JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8019653600 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRANGER MEDICAL SPECIALISTS LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.