Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 037820 | GA |
N | 207PE0004X | Emergency Medical Services | 037820 | GA |
N | 207PP0204X | Pediatric Emergency Physician | 037820 | GA |
N | 207Q00000X | Family Doctor | 037820 | GA |
N | 207QA0505X | Family Doctor - Adult Medicine | 037820 | GA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 037820 | GA |
N | 207QS0010X | Family Doctor - Sports Medicine | 037820 | GA |
NPI | 1063521631 |
---|---|
Provider Name | Dr. Kenneth L Grotz |
First Address | Augusta, GA 30914-3638 |
Second Address | Augusta, GA 30909 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2006 |
Last Update Date | 04/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00568235E | (05) | GA |
10062882 | AMERIGROUP (01) | |
1447352778 | NPI - CSRA EMERGENCY PHYS (01) | |
345518 | WELLCARE OF GA (01) | |
4370409 | AETNA (01) | |
E52978 | (02) | |
G38834 | (05) | SC |