Healthcare Provider Details

I. General information

NPI: 1215922000
Provider Name (Legal Business Name): MARK EDWARD MCGRANAHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 GEORGE E. CHANCE PARKWAY
CASEYVILLE IL
62232
US

IV. Provider business mailing address

1230 GEORGE E. CHANCE PARKWAY
CASEYVILLE IL
62232
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-5437
  • Fax:
Mailing address:
  • Phone: 618-345-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-111323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: