Healthcare Provider Details

I. General information

NPI: 1750797064
Provider Name (Legal Business Name): MATTHEW GRANGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E BROAD ST
COLUMBUS OH
43205-1015
US

IV. Provider business mailing address

473 W 12TH AVE STE 200
COLUMBUS OH
43210-1252
US

V. Phone/Fax

Practice location:
  • Phone: 614-252-8300
  • Fax:
Mailing address:
  • Phone: 614-293-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.15907-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number15907CNP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: