Provider Demographics
NPI:1083629893
Name:GROLEMUND, GARY M (DPM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:GROLEMUND
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3774
Mailing Address - Country:US
Mailing Address - Phone:912-264-6150
Mailing Address - Fax:912-264-5712
Practice Address - Street 1:10 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3774
Practice Address - Country:US
Practice Address - Phone:912-264-6150
Practice Address - Fax:912-264-5712
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000543213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000322033AMedicaid
GA000322033BMedicaid
GA480012915Medicare PIN
GA480004554Medicare PIN
GAT97612Medicare UPIN
GA202I480212Medicare PIN
GA48SCBDQMedicare PIN