Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | IL |
NPI | 1437366556 |
---|---|
Provider Name | Dr. Marie T Grothman |
First Address | Wheaton, IL 60187-3712 |
Second Address | Aurora, IL 60506-3178 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1710986179 | CLINIC NPI (01) | IL |
4515209 | BCBS (01) | ID |