=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093713695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANVILLE FAMILY MEDICINE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 PROFESSIONAL PARK STE A
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-2581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-7108
-----------------------------------------------------
Fax | 919-693-9245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PROFESSIONAL PARK STE A
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-2581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-7108
-----------------------------------------------------
Fax | 919-693-9245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DENNIS MICHAEL MAHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 919-693-7108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 25053
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25053
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------