Healthcare Provider Details

I. General information

NPI: 1588777510
Provider Name (Legal Business Name): MARIAN GRANSON AUDIOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 SOUTHERN BLVD
BRONX NY
10460-5980
US

IV. Provider business mailing address

390 1ST AVE #3B
NEW YORK NY
10010-4933
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000217
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: