Healthcare Provider Details

I. General information

NPI: 1891767299
Provider Name (Legal Business Name): EDWIN T MCGROARTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FALLS CANYON ROAD
AVALON CA
90704-1563
US

IV. Provider business mailing address

P.O. BOX 1563
AVALON CA
90704-1563
US

V. Phone/Fax

Practice location:
  • Phone: 310-510-0096
  • Fax: 310-510-2938
Mailing address:
  • Phone: 310-510-0096
  • Fax: 310-510-2938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number145912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: