1801865662 NPI number — DR. RICHARD L GROTZ M.D.

Table of content: DR. RICHARD L GROTZ M.D. (NPI 1801865662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801865662 NPI number — DR. RICHARD L GROTZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROTZ
Provider First Name:
RICHARD
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1801865662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 BELMONT ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-4430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
774-776-2991
Provider Business Mailing Address Fax Number:
774-776-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PEARL ST
Provider Second Line Business Practice Location Address:
SUITE 2700
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-2864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-584-4104
Provider Business Practice Location Address Fax Number:
508-584-4105
Provider Enumeration Date:
03/15/2006

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: 208600000X , with the licence number:  77137 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00092280 . This is a "RR MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 14-00003 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 300852540 . This is a "HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0013819 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 29256 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3109950 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77137 . This is a "TUFTS PROV#" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: GRJ13652 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 454450 . This is a "AETNA HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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