Provider Demographics
NPI:1093742272
Name:GROTH, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:GROTH
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 1:994 W JERICHO TPKE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3235
Mailing Address - Country:US
Mailing Address - Phone:631-543-1440
Mailing Address - Fax:631-543-1930
Practice Address - Street 1:994 W JERICHO TPKE
Practice Address - Street 2:SUITE 104
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3235
Practice Address - Country:US
Practice Address - Phone:631-543-1440
Practice Address - Fax:631-543-1930
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158610207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01491318Medicaid
NY02E171Medicare PIN
NY01491318Medicaid