Healthcare Provider Details

I. General information

NPI: 1720007404
Provider Name (Legal Business Name): TIMOTHY M GRONLIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N HILLSIDE
WICHITA KS
67214-4910
US

IV. Provider business mailing address

551 N. HILLSIDE SUITE 320
WICHITA KS
67214-4926
US

V. Phone/Fax

Practice location:
  • Phone: 316-962-2900
  • Fax: 316-962-7815
Mailing address:
  • Phone: 316-685-1367
  • Fax: 316-685-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0430825
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0430825
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-30825
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number0430825
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number04-30825
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: