1477766871 NPI number — MR. MICHAEL ROBERT GROHMAN IDC

Table of content: MR. MICHAEL ROBERT GROHMAN IDC (NPI 1477766871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477766871 NPI number — MR. MICHAEL ROBERT GROHMAN IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROHMAN
Provider First Name:
MICHAEL
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477766871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 555341
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMP PENDLETON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92055-5341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-725-5250
Provider Business Mailing Address Fax Number:
760-725-5298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41256 STEWART MESA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP PENDLETON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92055-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-725-5250
Provider Business Practice Location Address Fax Number:
760-725-5298
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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