Basic Information
| Provider Information | |||||||||
| NPI: | 1922501204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRNAK | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 S LEWIS PLZ | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296052944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642424122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 S LEWIS PLZ | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296052944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642424122 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2018 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101025371 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MDO.83463 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.