Provider Demographics
NPI:1104364702
Name:GROTH, THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GROTH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29856 STONY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA
Mailing Address - State:MN
Mailing Address - Zip Code:55925-4025
Mailing Address - Country:US
Mailing Address - Phone:507-458-0746
Mailing Address - Fax:
Practice Address - Street 1:29856 STONY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAKOTA
Practice Address - State:MN
Practice Address - Zip Code:55925-4025
Practice Address - Country:US
Practice Address - Phone:507-458-0746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist