Healthcare Provider Details

I. General information

NPI: 1376528182
Provider Name (Legal Business Name): RENEE J GROB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125-1 GREENTREE DR
DOVER DE
19904
US

IV. Provider business mailing address

125-1 GREENTREE DR
DOVER DE
19904
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-2788
  • Fax: 302-678-1765
Mailing address:
  • Phone: 302-674-2788
  • Fax: 302-678-1765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberC10004391
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: