MEDICARE: ALEXANDER JAMES GROTH

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	152W00000X	Optometrist	4901005121	MI

General Provider Information

NPI Number	:	1720571839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER JAMES GROTH

Provider Business Mailing Address
First Line	:	328 S HOUGHTON ST
Second Line	:
City	:	MILFORD
State	:	MI
Zip	:	48381-2414
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 W NORTH ST
Second Line	:	STE 104
City	:	JACKSON
State	:	MI
Zip	:	49202-3196
Country	:	US
Telephone Number	:	248-647-9790
Fax Number	:

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

Provider Enumeration Date	:	06/13/2018
Last Update Date	:	08/07/2019

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