Healthcare Provider Details

I. General information

NPI: 1558348110
Provider Name (Legal Business Name): WARREN S GROFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45465 FIFTH AVE CREDENTIALING DEPARTMENT
CALLAHAN FL
32011-3901
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-879-4544
  • Fax: 904-879-4411
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME62728
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: