1023030426 NPI number — DR. WESLEY DEE GRANGER M.D.

Table of content: DR. WESLEY DEE GRANGER M.D. (NPI 1023030426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023030426 NPI number — DR. WESLEY DEE GRANGER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANGER
Provider First Name:
WESLEY
Provider Middle Name:
DEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023030426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 PROFESSIONAL PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-4113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-856-2460
Provider Business Mailing Address Fax Number:
601-856-4687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 PROFESSIONAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-856-2460
Provider Business Practice Location Address Fax Number:
601-856-4687
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  11037 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 800050346 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 800050346 . This is a "MISSISSIPPI HEALTH PARTNE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 0017026 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 800050346 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 800050346 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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