Provider Demographics
NPI:1932169430
Name:GRANGE, TIMOTHY S (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:S
Last Name:GRANGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4052 PIONEER PKWY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2062
Mailing Address - Country:US
Mailing Address - Phone:801-955-1232
Mailing Address - Fax:801-955-1543
Practice Address - Street 1:4052 PIONEER PKWY
Practice Address - Street 2:SUITE 208
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2062
Practice Address - Country:US
Practice Address - Phone:801-955-1232
Practice Address - Fax:801-955-1543
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT891801521205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT891801521205OtherUTAH STATE ID
UT891801521205OtherUTAH STATE ID