Provider Demographics
NPI:1366462350
Name:DEGROOT, TERRY R (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:R
Last Name:DEGROOT
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 1:1617 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2543
Mailing Address - Country:US
Mailing Address - Phone:616-502-1997
Mailing Address - Fax:
Practice Address - Street 1:1617 SHELDON RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2543
Practice Address - Country:US
Practice Address - Phone:616-502-1997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038705207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB43773Medicare UPIN