Provider Demographics
NPI:1346203189
Name:GROMOV, SERGEI A (MD PHD)
Entity Type:Individual
Prefix:
First Name:SERGEI
Middle Name:A
Last Name:GROMOV
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 22ND PLACE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-725-7800
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3420 22ND PLACE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-725-1800
Practice Address - Fax:806-723-6532
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6922207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161584101Medicaid
TX161584101Medicaid
TX8B1143Medicare ID - Type Unspecified