Healthcare Provider Details

I. General information

NPI: 1588725253
Provider Name (Legal Business Name): PHILLIP MICHAEL GROB M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 COLLEGE AVE
SANTA ROSA CA
95401-5117
US

IV. Provider business mailing address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-0223
  • Fax: 707-573-0222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberG85079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: