MEDICARE: GRANGER MEDICAL SPECIALISTS, LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1497441539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANGER MEDICAL SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	7181 S CAMPUS VIEW DR STE 200
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-4312
Country	:	US
Telephone Number	:	801-965-3505
Fax Number	:

Provider Business Practice Location Address
First Line	:	6322 S 3000 E STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6931
Country	:	US
Telephone Number	:	801-352-5900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MARY JANE PENNINGTON
Credential	:	MD
Telephone Number	:	801-965-3600

Provider Enumeration Date	:	04/12/2023
Last Update Date	:	04/12/2023

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