Healthcare Provider Details

I. General information

NPI: 1124018866
Provider Name (Legal Business Name): TOMMIE MACK GRANGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 4TH ST BOX 30163
ALEXANDRIA LA
71301-8421
US

IV. Provider business mailing address

211 4TH ST BOX 30163
ALEXANDRIA LA
71301-8421
US

V. Phone/Fax

Practice location:
  • Phone: 318-767-5878
  • Fax: 318-767-5887
Mailing address:
  • Phone: 318-767-5878
  • Fax: 318-767-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number10146R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: