=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437116423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER LAWRENCE GROFF M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 OVERLOOK RD SUITE 412
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07901-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-598-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 BUXTON RD
-----------------------------------------------------
City | CHATHAM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07928-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-635-3614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 25MA03600900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------