MEDICARE: DR. MARK EDWARD MCGRANAHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-111323	IL

General Provider Information

NPI Number	:	1215922000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD MCGRANAHAN M.D.

Provider Business Mailing Address
First Line	:	1230 GEORGE E. CHANCE PARKWAY
Second Line	:
City	:	CASEYVILLE
State	:	IL
Zip	:	62232
Country	:	US
Telephone Number	:	618-345-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 GEORGE E. CHANCE PARKWAY
Second Line	:
City	:	CASEYVILLE
State	:	IL
Zip	:	62232
Country	:	US
Telephone Number	:	618-345-5437
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	08/13/2008

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