1457354045 NPI number — DR. BRIAN GRONERT MD

Table of content: DR. BRIAN GRONERT MD (NPI 1457354045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457354045 NPI number — DR. BRIAN GRONERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRONERT
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1457354045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-923-6770
Provider Business Mailing Address Fax Number:
505-923-5354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CENTRAL AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-841-1234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2005

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: 207L00000X , with the licence number:  2001-200 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 2001-200 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP3000X , with the licence number: ME69110 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP3000X , with the licence number: 2001-200 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 80729541 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1643587 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264798 . This is a "MARYLAND DEPT. OF LABOR" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: NM009G13 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 104477100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64907 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201029035 . This is a "PHP, SALUD, ETC..." identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 579617 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: B0966 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104477100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com