Healthcare Provider Details

I. General information

NPI: 1285894378
Provider Name (Legal Business Name): WESLEY DEE GRANGER, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PROFESSIONAL PKWY
RIDGELAND MS
39157-4113
US

IV. Provider business mailing address

12 PROFESSIONAL PKWY
RIDGELAND MS
39157-4113
US

V. Phone/Fax

Practice location:
  • Phone: 601-856-2460
  • Fax: 601-856-4687
Mailing address:
  • Phone: 601-856-2460
  • Fax: 601-856-4687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number11037
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number11037
License Number StateMS

VIII. Authorized Official

Name: WESLEY DEE GRANGER
Title or Position: OWNER
Credential: M.D.
Phone: 601-856-2460