Provider Demographics
NPI:1477636868
Name:GROGAN, KEVIN J (C-PED)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:GROGAN
Suffix:
Gender:M
Credentials:C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 ASBURY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2900
Mailing Address - Country:US
Mailing Address - Phone:563-557-1651
Mailing Address - Fax:563-557-0073
Practice Address - Street 1:3330 ASBURY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2900
Practice Address - Country:US
Practice Address - Phone:563-557-1651
Practice Address - Fax:563-557-0073
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IANONE174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0264473Medicaid
IA0264473Medicaid