Provider Demographics
NPI:1134470222
Name:PROLO & INTEGRATED MEDICINE, LLC
Entity Type:Organization
Organization Name:PROLO & INTEGRATED MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-362-5227
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-0297
Mailing Address - Country:US
Mailing Address - Phone:973-362-5227
Mailing Address - Fax:973-250-0045
Practice Address - Street 1:532 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-4411
Practice Address - Country:US
Practice Address - Phone:973-362-5227
Practice Address - Fax:973-250-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03954800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0341401Medicaid
NJ485624PXEMedicare PIN
NJGR485624Medicare Oscar/Certification
NJC54086Medicare UPIN