Basic Information
| Provider Information | |||||||||
| NPI: | 1578876116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | CARLBERG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLBERG | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5255 E STOP 11 RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462376341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284723 | ||||||||
| FaxNumber: | 3175284699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 03/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 63083 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | 4301096543 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 01077262A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
No ID Information.