Provider Demographics
NPI:1194784900
Name:GRANITE MOUNTAIN NEUROLOGY, PC
Entity type:Organization
Organization Name:GRANITE MOUNTAIN NEUROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-771-2338
Mailing Address - Street 1:802 AINSWORTH DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1630
Mailing Address - Country:US
Mailing Address - Phone:928-771-2338
Mailing Address - Fax:928-771-2339
Practice Address - Street 1:802 AINSWORTH DR
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1630
Practice Address - Country:US
Practice Address - Phone:928-771-2338
Practice Address - Fax:928-771-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG15888Medicare UPIN
AZ65532Medicare ID - Type Unspecified