Healthcare Provider Details

I. General information

NPI: 1093713695
Provider Name (Legal Business Name): GRANVILLE FAMILY MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PROFESSIONAL PARK STE A
OXFORD NC
27565-2581
US

IV. Provider business mailing address

103 PROFESSIONAL PARK STE A
OXFORD NC
27565-2581
US

V. Phone/Fax

Practice location:
  • Phone: 919-693-7108
  • Fax: 919-693-9245
Mailing address:
  • Phone: 919-693-7108
  • Fax: 919-693-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25053
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25053
License Number StateNC

VIII. Authorized Official

Name: DENNIS MICHAEL MAHAN
Title or Position: CEO
Credential: MD
Phone: 919-693-7108