Provider Demographics
NPI:1467456400
Name:GROOS, FRED L (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:L
Last Name:GROOS
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 1:301 EXPLORER ST
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-2813
Mailing Address - Country:US
Mailing Address - Phone:906-346-4924
Mailing Address - Fax:906-346-6474
Practice Address - Street 1:1414 W FAIR AVE STE 242
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5406
Practice Address - Country:US
Practice Address - Phone:906-449-2900
Practice Address - Fax:906-449-2975
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28880-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31367800Medicaid
WI521823OtherMEDICARE PART A - CLINIC
WI521824OtherMEDICARE A MOBIL UNIT
WI31367800Medicaid
WI521824OtherMEDICARE A MOBIL UNIT