MEDICARE: DR. BRIAN K GRANGER M.D.05

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	207Q00000X	Family Medicine Physician	022624	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487658274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN K GRANGER M.D.05

Provider Business Mailing Address
First Line	:	201 W GLORIA SWITCH RD
Second Line	:	SUITE I
City	:	LAFAYETTE
State	:	LA
Zip	:	70507-2590
Country	:	US
Telephone Number	:	337-565-6012
Fax Number	:	337-565-6014

Provider Business Practice Location Address
First Line	:	201 W GLORIA SWITCH RD
Second Line	:	SUITE I
City	:	LAFAYETTE
State	:	LA
Zip	:	70507-2590
Country	:	US
Telephone Number	:	337-565-6012
Fax Number	:	337-565-6014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/08/2007

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