Healthcare Provider Details

I. General information

NPI: 1396716163
Provider Name (Legal Business Name): JOHN R GROLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 STATE ST
CHESTER IL
62233-1116
US

IV. Provider business mailing address

1028 S KIRKWOOD RD STE A
KIRKWOOD MO
63122-7222
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-4581
  • Fax: 318-826-5152
Mailing address:
  • Phone: 314-441-5609
  • Fax: 314-288-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR8J11
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-094904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: