Provider Demographics
NPI:1518978840
Name:GROENEWOLD, ROBERT J (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:GROENEWOLD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1016
Mailing Address - Country:US
Mailing Address - Phone:605-322-2754
Mailing Address - Fax:605-322-2727
Practice Address - Street 1:800 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1016
Practice Address - Country:US
Practice Address - Phone:605-322-2754
Practice Address - Fax:605-322-2727
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR026334 - 0461367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0006659OtherSD BLUE CROSS
MN051K0GROtherMN BLUE CROSS
IA0573980Medicaid
NE460224743-48Medicaid
SDR026334OtherDAKOTACARE PROVIDER #
SD5753700Medicaid
SD460224743-57105-AC41OtherTRICARE PROVIDER #
NE460224743-48Medicaid