Basic Information
| Provider Information | |||||||||
| NPI: | 1013414721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANRUD | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | OLAV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256900 | ||||||||
| FaxNumber: | 2086256910 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256900 | ||||||||
| FaxNumber: | 2086256710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 65851 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 29289 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | M-15879 | ID | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.