Healthcare Provider Details

I. General information

NPI: 1356425672
Provider Name (Legal Business Name): GRANGER MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E 4500 S SUITE 200
SALT LAKE CITY UT
84107-3906
US

IV. Provider business mailing address

3725 W 4100 S
WEST VALLEY CITY UT
84120-5530
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-9800
  • Fax: 801-262-8300
Mailing address:
  • Phone: 801-965-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number164813-1205
License Number StateUT

VIII. Authorized Official

Name: DR. MARY JANE PENNINGTON
Title or Position: BOARD MEMBER
Credential: M.D.
Phone: 801-965-3600