NPIMap

Organization Active NPI

Granger Medical Clinic PC

  • Family Medicine Physician
  • Draper, UT
National Provider Identifier
1174968051
Registry record updated Dec 13, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
GRANGER MEDICAL CLINIC PC
Practice address
11724 South State St.
Draper, UT 84020
Phone
(801) 965-3600
Fax
(801) 965-3740
NPI assigned
May 6, 2013
Last updated
Dec 13, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
GRANGER MEDICAL CLINIC PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 13, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mary Jane PenningtonNPI 1205868452
Title
President
Phone
(801) 965-3600

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X
Family Medicine Physician 207Q00000X Primary
Internal Medicine Physician 207R00000X
Gastroenterology Physician 207RG0100X
Nephrology Physician 207RN0300X
Pulmonary Disease Physician 207RP1001X
Sports Medicine (Internal Medicine) Physician 207RS0010X
Obstetrics & Gynecology Physician 207V00000X
Ophthalmology Physician 207W00000X
Orthopaedic Surgery Physician 207X00000X
Otolaryngology Physician 207Y00000X
Pediatrics Physician 208000000X
Plastic Surgery Physician 208200000X
Pain Medicine Physician 208VP0000X
Sleep Medicine (Internal Medicine) Physician 207RS0012X

Addresses

Primary practice location

11724 South State St.
Draper, UT 84020

Mailing address

2965 W 3500 S
West Valley City, UT 84119-3602
Phone (801) 965-3600

Other names 1

  • Granger Medical Draper Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031105000159 UT Part B Supplier - Clinic/Group Practice 3476465691 Receives reassigned benefits from 239 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Salt Lake City, UT; Sandy, UT; Tooele, UT; West Jordan, UT; West Valley City, UT; Draper, UT; American Fork, UT; Bountiful, UT…

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
46D2069689Granger Medical Clinic - Draper11724 South State St, Draper, UT 84020Provider-performed microscopySep 27, 2026

National Provider Directory

National Provider Directory
Part of
Granger Medical Clinica

Practitioners & affiliated clinicians

Practitioners 33

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 33

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1367798400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1702425600000",
    "number": "1174968051",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2965 W 3500 S",
            "city": "WEST VALLEY CITY",
            "state": "UT",
            "postal_code": "841193602",
            "telephone_number": "801-965-3600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11724 SOUTH STATE ST.",
            "city": "DRAPER",
            "state": "UT",
            "postal_code": "84020",
            "telephone_number": "801-965-3600",
            "fax_number": "801-965-3740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRANGER MEDICAL CLINIC PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GRANGER MEDICAL CLINIC PC",
        "enumeration_date": "2013-05-06",
        "last_updated": "2023-12-13",
        "certification_date": "2023-12-13",
        "status": "A",
        "authorized_official_last_name": "PENNINGTON",
        "authorized_official_first_name": "MARY JANE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "801-965-3600"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RS0010X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Sports Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RS0012X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Sleep Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Granger Medical Draper",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Granger Medical Draper",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Draper, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.