=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730199704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN LUIS GRANADOS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 02/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3024 NEW BERN AVE SUITE 306 - OB/GYN
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-350-8535
-----------------------------------------------------
Fax | 919-350-8310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3024 NEW BERN AVE SUITE 300
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-350-8228
-----------------------------------------------------
Fax | 919-350-7976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 30912
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VM0101X
-----------------------------------------------------
Taxonomy Name | Maternal & Fetal Medicine Physician
-----------------------------------------------------
License Number | 30912
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------