Provider Demographics
NPI:1093700593
Name:GRONHOLZ-DERO, M JILL
Entity Type:Individual
Prefix:
First Name:M
Middle Name:JILL
Last Name:GRONHOLZ-DERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4927
Mailing Address - Country:US
Mailing Address - Phone:208-765-5922
Mailing Address - Fax:208-664-3169
Practice Address - Street 1:914 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4927
Practice Address - Country:US
Practice Address - Phone:208-765-5922
Practice Address - Fax:208-664-3169
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-45207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E19318Medicare UPIN
ID1302782Medicare ID - Type Unspecified
ID1790296Medicare ID - Type Unspecified