MEDICARE: DR. EDWARD SCOTT GRONKA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	035431	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306838099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD SCOTT GRONKA M.D.

Provider Business Mailing Address
First Line	:	874 W LANIER AVE
Second Line	:	ONE PRESTIGE PARK SUITE 100
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-1511
Country	:	US
Telephone Number	:	770-461-4000
Fax Number	:	770-461-2790

Provider Business Practice Location Address
First Line	:	874 W LANIER AVE
Second Line	:	ONE PRESTIGE PARK SUITE 100
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-1511
Country	:	US
Telephone Number	:	770-461-4000
Fax Number	:	770-461-2790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	08/28/2007

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