Healthcare Provider Details

I. General information

NPI: 1245482470
Provider Name (Legal Business Name): TIMOTHY P GRANNELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLENTANGY RIVER RD
COLUMBUS OH
43202-1523
US

IV. Provider business mailing address

3400 OLENTANGY RIVER RD
COLUMBUS OH
43202-1523
US

V. Phone/Fax

Practice location:
  • Phone: 614-754-5500
  • Fax: 614-754-5501
Mailing address:
  • Phone: 614-754-5500
  • Fax: 614-754-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3775
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.14096-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: