Healthcare Provider Details

I. General information

NPI: 1881649754
Provider Name (Legal Business Name): TED GROSHONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N KEENE ST STE 101
COLUMBIA MO
65201-6986
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-6921
  • Fax: 573-882-1154
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD31289
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: