1457340986 NPI number — RODNEY E GROLMAN MD

Table of content: RODNEY E GROLMAN MD (NPI 1457340986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457340986 NPI number — RODNEY E GROLMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROLMAN
Provider First Name:
RODNEY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1457340986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/25/2005
NPI Reactivation Date:
05/08/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 S PIONEER WAY
Provider Second Line Business Mailing Address:
SUITE 370
Provider Business Mailing Address City Name:
MOSES LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98837-4613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-218-8059
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 S PIONEER WAY
Provider Second Line Business Practice Location Address:
SUITE 370
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-4613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-218-8059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2005

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: 208600000X , with the licence number:  C53617 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD60050963 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1334455 . This is a "AETNA HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 402277700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145724700 . This is a "FEDERAL WORKMAN'S COMP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 887BAA62011004 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K5850005 . This is a "CAREFIRST DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: P00354284 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7843490 . This is a "AETNA PPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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