=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619979374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE LYNN GROCH D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2005
-----------------------------------------------------
Last Update Date | 03/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 W 6TH ST SUITE 210
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-2525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-349-5828
-----------------------------------------------------
Fax | 315-349-5829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 W 6TH ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-349-5511
-----------------------------------------------------
Fax | 315-349-5921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 34-008578
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 35008578
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 269960
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------