Provider Demographics
NPI:1992785497
Name:GRANET, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GRANET
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 1:621 S NEW BALLAS RD STE 560A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8261
Mailing Address - Country:US
Mailing Address - Phone:314-251-6440
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 560A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8261
Practice Address - Country:US
Practice Address - Phone:314-251-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428351208600000X
MO20220142392086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03064642Medicaid
PA1017255980001Medicaid
PA107282Medicare Oscar/Certification
PA1017255980001Medicaid