MEDICARE: JACKIE L GROSKLOS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	R9H27	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	002013185	OTHER	MO	MEDICARE PROV ID AREA 99
3	003012762	OTHER	MO	MEDICARE PROVIDER ID
4	060049013	OTHER	MO	RR MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CD6536	OTHER	MO	RR GROUP 01

General Provider Information

NPI Number	:	1245223239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE L GROSKLOS MD

Provider Business Mailing Address
First Line	:	450 N NEW BALLAS RD
Second Line	:	STE 270 W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-2632
Country	:	US
Telephone Number	:	314-991-6969
Fax Number	:	314-997-6969

Provider Business Practice Location Address
First Line	:	450 N NEW BALLAS RD
Second Line	:	STE 270 W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-2632
Country	:	US
Telephone Number	:	314-991-6969
Fax Number	:	314-997-6969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	01/19/2016

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Directions to “ JACKIE L GROSKLOS MD” Practice Location

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