Healthcare Provider Details

I. General information

NPI: 1922675693
Provider Name (Legal Business Name): JARED MATHEW GROOTWASSINK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14001 RIDGEDALE DR STE 200
MINNETONKA MN
55305-1747
US

IV. Provider business mailing address

PO BOX 19640
SPRINGFIELD IL
62794-9640
US

V. Phone/Fax

Practice location:
  • Phone: 952-249-2000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-7958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number78992
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125.077905
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: