MEDICARE: DR. DAVID ROBERT GROH PH.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	103TC0700X	Clinical Psychologist	20042574A	IN
2	103TC0700X	Clinical Psychologist	2938-057	WI

General Provider Information

NPI Number	:	1356614267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID ROBERT GROH PH.D.

Provider Business Mailing Address
First Line	:	28208 STATE ROUTE 1
Second Line	:	SUITE 101
City	:	WEST HARRISON
State	:	IN
Zip	:	47060-9686
Country	:	US
Telephone Number	:	812-576-1600
Fax Number	:	812-576-1602

Provider Business Practice Location Address
First Line	:	28208 STATE ROUTE 1
Second Line	:	SUITE 101
City	:	WEST HARRISON
State	:	IN
Zip	:	47060-9686
Country	:	US
Telephone Number	:	812-576-1600
Fax Number	:	812-576-1602

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

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	03/06/2012

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