Provider Demographics
NPI:1508930421
Name:GROTZINGER, MARK DANIEL (ATC, PES)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DANIEL
Last Name:GROTZINGER
Suffix:
Gender:M
Credentials:ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-6659
Mailing Address - Country:US
Mailing Address - Phone:814-418-0514
Mailing Address - Fax:
Practice Address - Street 1:KENNETH LANGONE SPORTS MEDICINE CENTER
Practice Address - Street 2:ONE DENT DR.
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837
Practice Address - Country:US
Practice Address - Phone:814-418-0514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0038232255A2300X
RIAT002872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer