Healthcare Provider Details

I. General information

NPI: 1124037650
Provider Name (Legal Business Name): ROBERT JEFF GRONDEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

IV. Provider business mailing address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

V. Phone/Fax

Practice location:
  • Phone: 208-273-7700
  • Fax: 702-565-8898
Mailing address:
  • Phone: 208-273-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM16347
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM16347
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: