Healthcare Provider Details

I. General information

NPI: 1467611962
Provider Name (Legal Business Name): JAN CASIMIR GROBLEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 DUDLEY ST
PROVIDENCE RI
02905-2403
US

IV. Provider business mailing address

118 DUDLEY ST
PROVIDENCE RI
02905-2403
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-2300
  • Fax:
Mailing address:
  • Phone: 401-274-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD037214
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: