Healthcare Provider Details

I. General information

NPI: 1922501204
Provider Name (Legal Business Name): JORDAN J GRNAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S LEWIS PLZ
GREENVILLE SC
29605-2944
US

IV. Provider business mailing address

5 S LEWIS PLZ
GREENVILLE SC
29605-2944
US

V. Phone/Fax

Practice location:
  • Phone: 864-242-4122
  • Fax:
Mailing address:
  • Phone: 864-242-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101025371
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMDO.83463
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: