Healthcare Provider Details

I. General information

NPI: 1427163492
Provider Name (Legal Business Name): TERENCE M GROGAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TERENCE MICHAEL GROGAN

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 S ALABAMA ST STE 100
INDIANAPOLIS IN
46225-3301
US

IV. Provider business mailing address

1550 E STATE ROAD 44
CONNERSVILLE IN
47331-8293
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-2489
  • Fax: 317-528-3770
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101017356
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48857
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number102050142
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005401A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: