Healthcare Provider Details

I. General information

NPI: 1306838099
Provider Name (Legal Business Name): EDWARD SCOTT GRONKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 W LANIER AVE ONE PRESTIGE PARK SUITE 100
FAYETTEVILLE GA
30214-1511
US

IV. Provider business mailing address

874 W LANIER AVE ONE PRESTIGE PARK SUITE 100
FAYETTEVILLE GA
30214-1511
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-4000
  • Fax: 770-461-2790
Mailing address:
  • Phone: 770-461-4000
  • Fax: 770-461-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number035431
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: