Provider Demographics
NPI:1417978776
Name:GROTHAUS, MATTHEW C (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:GROTHAUS
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 1:208 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1299
Mailing Address - Country:US
Mailing Address - Phone:419-542-5669
Mailing Address - Fax:419-542-5667
Practice Address - Street 1:208 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526
Practice Address - Country:US
Practice Address - Phone:419-542-5669
Practice Address - Fax:419-542-5667
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087589207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2791331Medicaid
OH35-087589OtherLICENSE
OHP00453968OtherRAILROAD
OH2791331Medicaid
OH4220683Medicare PIN
OH4220684Medicare PIN