Provider Demographics
NPI:1285894378
Name:WESLEY DEE GRANGER, M.D., P.A.
Entity type:Organization
Organization Name:WESLEY DEE GRANGER, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-856-2460
Mailing Address - Street 1:12 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4113
Mailing Address - Country:US
Mailing Address - Phone:601-856-2460
Mailing Address - Fax:601-856-4687
Practice Address - Street 1:12 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4113
Practice Address - Country:US
Practice Address - Phone:601-856-2460
Practice Address - Fax:601-856-4687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11037305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017026Medicaid
MS00017026Medicaid
MS110000443Medicare PIN