MEDICARE: GRANITE PEAKS ENDOSCOPY,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1083758320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE PEAKS ENDOSCOPY,LLC

Provider Business Mailing Address
First Line	:	10150 S PETUNIA WAY STE B
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4328
Country	:	US
Telephone Number	:	801-619-9000
Fax Number	:	801-619-9000

Provider Business Practice Location Address
First Line	:	10150 SOUTH PETUNIA WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4380
Country	:	US
Telephone Number	:	801-619-9000
Fax Number	:	801-619-9001

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ANDREW HEINER
Credential	:	MD
Telephone Number	:	801-619-9000

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	01/21/2021

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