1073714580 NPI number — DR. JAMES R GRANGER III MD

Table of content: DR. JAMES R GRANGER III MD (NPI 1073714580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073714580 NPI number — DR. JAMES R GRANGER III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANGER
Provider First Name:
JAMES
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1073714580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1521 JOHNSON FERRY RD STE 135
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-6408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-247-2115
Provider Business Mailing Address Fax Number:
404-393-8059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 JOHNSON FERRY RD STE 135
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-6408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-247-2115
Provider Business Practice Location Address Fax Number:
404-393-8059
Provider Enumeration Date:
05/30/2007

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: 208D00000X , with the licence number:  55824 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0401X , with the licence number: 55824 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 55824 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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