1063502912 NPI number — WENDELL A GROGAN MD

Table of content: WENDELL A GROGAN MD (NPI 1063502912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063502912 NPI number — WENDELL A GROGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROGAN
Provider First Name:
WENDELL
Provider Middle Name:
A
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:
1063502912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-9547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-359-5981
Provider Business Mailing Address Fax Number:
281-359-3591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22999 HIGHWAY 59 N STE 416
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77339-4412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-359-5981
Provider Business Practice Location Address Fax Number:
281-359-3591
Provider Enumeration Date:
10/13/2006

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: 2084S0012X , with the licence number:  M0740 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: M0740 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0600X , with the licence number: M0740 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1590675 . This is a "FIRST HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0026MH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 6700232 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 172034401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 635873 . This is a "MHHNP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4462988 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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