Healthcare Provider Details

I. General information

NPI: 1417978776
Provider Name (Legal Business Name): MATTHEW C GROTHAUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 COLUMBUS ST
HICKSVILLE OH
43526
US

IV. Provider business mailing address

208 COLUMBUS ST
HICKSVILLE OH
43526-1299
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-5669
  • Fax: 419-542-5667
Mailing address:
  • Phone: 419-542-5669
  • Fax: 419-542-5667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35087589
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: