Healthcare Provider Details

I. General information

NPI: 1205681327
Provider Name (Legal Business Name): MITCHELL JOSEPH GROOME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7691 POPLAR AVE
GERMANTOWN TN
38138-3904
US

IV. Provider business mailing address

6268 SKYVIEW CIR
BARTLETT TN
38135-2434
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-6000
  • Fax:
Mailing address:
  • Phone: 901-461-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148849
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number238751
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: