Basic Information
| Provider Information | |||||||||
| NPI: | 1952426983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAINGER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215490677 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 W COCOA BEACH CSWY | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217997192 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 200500993 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085B0100X | ME98264 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 200500993 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME98264 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04621 | 01 | BCBS | OTHER | AD657X | 01 | MEDICARE PTAN | OTHER | M9568 | 01 | FL | MEDICARE HF | OTHER | 104337300 | 05 | FL | MEDICAID |