Healthcare Provider Details

I. General information

NPI: 1639408404
Provider Name (Legal Business Name): JOHNSON AND GROTE PEDIATRICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 E 34TH ST STE 203
JOPLIN MO
64804-3967
US

IV. Provider business mailing address

702 E 34TH ST STE 203
JOPLIN MO
64804-3967
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-4077
  • Fax: 417-623-5171
Mailing address:
  • Phone: 417-623-4077
  • Fax: 417-623-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND GROTE
Title or Position: PHYSICIAN
Credential: MD
Phone: 417-623-4077