Provider Demographics
NPI:1124128491
Name:GRANSON, ALFRED JR (MD, LLC)
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:
Last Name:GRANSON
Suffix:JR
Gender:M
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2831
Mailing Address - Country:US
Mailing Address - Phone:419-589-9700
Mailing Address - Fax:419-589-2731
Practice Address - Street 1:70 MADISON RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2831
Practice Address - Country:US
Practice Address - Phone:419-589-9700
Practice Address - Fax:419-589-2731
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072595G174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2136683Medicaid
OHP00818354OtherRAILROAD MEDICARE GROUP
OH000000142322OtherANTHEM BC/BS OF OHIO
OHDQ1487OtherRAILROAD MEDICARE INDIVIDUAL
OH9387391OtherMEDICARE GROUP
OH2136683Medicaid
OH0878253Medicare PIN
OH9387391OtherMEDICARE GROUP