Provider Demographics
NPI:1699050823
Name:GRANGER MEDICAL PARK CITY
Entity type:Organization
Organization Name:GRANGER MEDICAL PARK CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-965-3600
Mailing Address - Street 1:1600 SNOW CREEK DR STE B
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7372
Mailing Address - Country:US
Mailing Address - Phone:801-569-5520
Mailing Address - Fax:801-352-5951
Practice Address - Street 1:3181 W 9000 SO
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-569-5520
Practice Address - Fax:801-352-5951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-19
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004880Medicare PIN