Healthcare Provider Details

I. General information

NPI: 1942203419
Provider Name (Legal Business Name): THOMAS J GROEGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 CHARLES ST
DEADWOOD SD
57732
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MSS
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-717-6431
  • Fax: 605-719-6471
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2775
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: