Provider Demographics
NPI:1407054455
Name:GROMOLL, MARGO AIDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARGO
Middle Name:AIDAN
Last Name:GROMOLL
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 1:1501 E GARDNER LN APT 718
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-3627
Mailing Address - Country:US
Mailing Address - Phone:979-966-3028
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics