Provider Demographics
NPI:1245223239
Name:GROSKLOS, JACKIE L (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:GROSKLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N NEW BALLAS RD
Mailing Address - Street 2:STE 270 W
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2632
Mailing Address - Country:US
Mailing Address - Phone:314-991-6969
Mailing Address - Fax:314-997-6969
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:STE 270 W
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63195-2632
Practice Address - Country:US
Practice Address - Phone:314-991-6969
Practice Address - Fax:314-997-6969
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9H27207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCD6536OtherRR GROUP 01
MO002013185OtherMEDICARE PROV ID AREA 99
MO003012762OtherMEDICARE PROVIDER ID
MO060049013OtherRR MEDICARE NUMBER
MOCD6536OtherRR GROUP 01