Healthcare Provider Details

I. General information

NPI: 1184039976
Provider Name (Legal Business Name): DANIEL ROBERT GRUTTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NORTH EAST AVE ANESTHESIA DEPARTMENT
JACKSON MI
49201
US

IV. Provider business mailing address

2006 HOGBACK RD STE 5A
ANN ARBOR MI
48105-9750
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3240
  • Fax:
Mailing address:
  • Phone: 734-263-2400
  • Fax: 734-773-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5101023010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: