Healthcare Provider Details

I. General information

NPI: 1649451907
Provider Name (Legal Business Name): GROS VENTRE OB/GYN, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 108
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 3306
IDAHO FALLS ID
83403-3306
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-1005
  • Fax: 307-734-1065
Mailing address:
  • Phone: 307-734-1005
  • Fax: 307-734-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MAURA LOFARO
Title or Position: OWNER
Credential: MD
Phone: 307-734-1005