Healthcare Provider Details

I. General information

NPI: 1457593865
Provider Name (Legal Business Name): JESSE GROH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 S SAINT PETERS PKWY SUITE A
SAINT PETERS MO
63303-6355
US

IV. Provider business mailing address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-5437
  • Fax:
Mailing address:
  • Phone: 636-587-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN1659
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010007576
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: