MEDICARE: DR. KURT THOMAS GROZINGER M.D.

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	2085R0202X	Diagnostic Radiology Physician	05413R	LA
2	2085B0100X	Body Imaging Physician	05413R	LA
3	2085R0202X	Diagnostic Radiology Physician	MD.05413R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05413R	OTHER	LA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1548264211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KURT THOMAS GROZINGER M.D.

Provider Business Mailing Address
First Line	:	1512 W KIRBY PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3822
Country	:	US
Telephone Number	:	318-626-0287
Fax Number	:

Provider Business Practice Location Address
First Line	:	2105 AIRLINE DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-3105
Country	:	US
Telephone Number	:	318-741-6078
Fax Number	:

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	04/12/2022

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