Healthcare Provider Details

I. General information

NPI: 1235218439
Provider Name (Legal Business Name): BRIAN GROGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 W BAVARIA ST
EAGLE ID
83616-5171
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-6200
  • Fax: 208-302-6255
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG63543
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21573
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2971884
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: