=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962207480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT GROSHOLZ EDWARDS DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2025
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S HUDSON AVE
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-683-8536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2048 E VILLA ST APT 2
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-2355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-574-9688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 307582
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------