Healthcare Provider Details

I. General information

NPI: 1275638777
Provider Name (Legal Business Name): SUZANNE M GRANNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/27/2023
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 OAKLANDON ROAD SUITE 130
INDIANAPOLIS IN
46236-9543
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-1111
  • Fax: 317-621-1110
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01057464
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01057464A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: