Healthcare Provider Details

I. General information

NPI: 1538363080
Provider Name (Legal Business Name): GLENN EDWARD GROAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14551 HOPE CENTER LOOP STE 100
FORT MYERS FL
33912-4705
US

IV. Provider business mailing address

3660 BROADWAY
FORT MYERS FL
33901-8005
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-2316
  • Fax: 239-936-3099
Mailing address:
  • Phone: 239-936-2316
  • Fax: 239-936-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA115605
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME125326
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: