Healthcare Provider Details

I. General information

NPI: 1154881878
Provider Name (Legal Business Name): GINA RAE GROSHEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 07/26/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5366 386TH ST NE
NORTH BRANCH MN
55056-5833
US

IV. Provider business mailing address

8353 IRONWOOD TRL
CHISAGO CITY MN
55013
US

V. Phone/Fax

Practice location:
  • Phone: 855-324-7843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67605
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: