MEDICARE: VICTOR JOSE ANCIANO GRANADILLO MD

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	207X00000X	Orthopaedic Surgery Physician	55434	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0397730024	OTHER	NC	NSC#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841686995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR JOSE ANCIANO GRANADILLO MD

Provider Business Mailing Address
First Line	:	PO BOX 909
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40201-0909
Country	:	US
Telephone Number	:	502-588-0328
Fax Number	:

Provider Business Practice Location Address
First Line	:	4402 CHURCHMAN AVE STE 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40215-3101
Country	:	US
Telephone Number	:	502-363-0588
Fax Number	:	502-363-0972

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

Provider Enumeration Date	:	04/15/2015
Last Update Date	:	08/24/2021

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