1902884950 NPI number — GERALD E GRONBORG DPM

Table of content: GERALD E GRONBORG DPM (NPI 1902884950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902884950 NPI number — GERALD E GRONBORG DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRONBORG
Provider First Name:
GERALD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1902884950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2727 BEALE AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ALTOONA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16601-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-946-1075
Provider Business Mailing Address Fax Number:
814-946-4076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 BEALE AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ALTOONA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16601-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-946-1075
Provider Business Practice Location Address Fax Number:
814-946-4076
Provider Enumeration Date:
01/09/2006

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: 213EP1101X , with the licence number:  SC003442L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: SC003442L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: SC003442L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ER0200X , with the licence number: SC003442L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0012762560012 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5166987 . This is a "PPNI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 826758 . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000706203 . This is a "KEYSTONE HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CC2226 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P 54229714 . This is a "MULTIPLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012762560009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0012762560010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0857830000 . This is a "PPO PROGRAM INDEPENDENCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 200069 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2805196 . This is a "AETNA HMO QPOS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 21128765012 . This is a "BEECH STREET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 480013965 . This is a "RR MEDICARE INDIVIDUAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1022107 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7318023 . This is a "MAMSI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: GR706203 . This is a "BLUE SHIELD INDIVIDUAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000060525 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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