Provider Demographics
NPI:1033189105
Name:GROTZ, GREGORY RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RICHARD
Last Name:GROTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 UNIVERSITY AVE
Mailing Address - Street 2:PO BOX 1655
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52004-1655
Mailing Address - Country:US
Mailing Address - Phone:563-556-6895
Mailing Address - Fax:563-556-3618
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6009
Practice Address - Country:US
Practice Address - Phone:207-784-2554
Practice Address - Fax:207-777-1439
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0630981762085R0202X
WI401360202085R0202X
IA323912085R0202X
MEMD186512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1033189105Medicaid
IA2175521Medicaid
IA1175521Medicaid
IA2175521Medicaid
IAG71312Medicare UPIN
IA1175521Medicaid
IA0175521Medicaid