=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124024914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY A GROOM PHD, CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11200 SW 8TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33199-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-348-7747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 NE 93RD ST
-----------------------------------------------------
City | MIAMI SHORES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33138-2854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-348-7725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 1322612
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------