MEDICARE: MARY ELIZABETH GROTH A.P.R.N., P.M.H.S.

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	363LP0200X	Pediatric Nurse Practitioner	001632	CT

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	:	1508849076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH GROTH A.P.R.N., P.M.H.S.

Provider Business Mailing Address
First Line	:	P.O. BOX 589
Second Line	:	59 LYME STREET
City	:	OLD LYME
State	:	CT
Zip	:	06371
Country	:	US
Telephone Number	:	860-373-6208
Fax Number	:	860-434-1580

Provider Business Practice Location Address
First Line	:	59 LYME STREET
Second Line	:
City	:	OLD LYME
State	:	CT
Zip	:	06371
Country	:	US
Telephone Number	:	860-373-6208
Fax Number	:	860-434-1580

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	12/12/2017

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