Healthcare Provider Details

I. General information

NPI: 1265665178
Provider Name (Legal Business Name): BRIAN MICHAEL GRONEWOLD M.ED.,ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER ST
MOBILE AL
36604-1541
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-665-8200
  • Fax: 251-665-8210
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number994
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1896
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: