Healthcare Provider Details

I. General information

NPI: 1699716746
Provider Name (Legal Business Name): DEBRA A. GROOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 INTERNATIONAL WAY
SPRINGFIELD OR
97477-1047
US

IV. Provider business mailing address

PO BOX 72059
SPRINGFIELD OR
97475-0285
US

V. Phone/Fax

Practice location:
  • Phone: 541-341-8033
  • Fax: 541-341-8099
Mailing address:
  • Phone: 541-341-8033
  • Fax: 541-341-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD25384
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: