Basic Information
| Provider Information | |||||||||
| NPI: | 1881797876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANGER MEDICAL CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRANGER MEDICAL RIVERTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
| FaxNumber: | 8013021714 | ||||||||
| Practice Location | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
| FaxNumber: | 8013021714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | MARY JANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8019653417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRANGER MEDICAL CLINIC INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.