MEDICARE: DR. TIMOTHY S GRANGE 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	208100000X	Physical Medicine & Rehabilitation Physician	891801521205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	891801521205	OTHER	UT	UTAH STATE ID

General Provider Information

NPI Number	:	1932169430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY S GRANGE MD

Provider Business Mailing Address
First Line	:	4052 PIONEER PKWY
Second Line	:	SUITE 208
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-2062
Country	:	US
Telephone Number	:	801-955-1232
Fax Number	:	801-955-1543

Provider Business Practice Location Address
First Line	:	4052 PIONEER PKWY
Second Line	:	SUITE 208
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-2062
Country	:	US
Telephone Number	:	801-955-1232
Fax Number	:	801-955-1543

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	07/03/2009

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Directions to “ DR. TIMOTHY S GRANGE MD” Practice Location

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