Provider Demographics
NPI:1568776847
Name:GROEN, KIMBERLY I (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:I
Last Name:GROEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:I
Other - Last Name:REICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:805 BLOOMFIELD ST
Mailing Address - Street 2:#3
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-7001
Mailing Address - Country:US
Mailing Address - Phone:813-469-9593
Mailing Address - Fax:
Practice Address - Street 1:805 BLOOMFIELD ST
Practice Address - Street 2:#3
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-7001
Practice Address - Country:US
Practice Address - Phone:813-469-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS016747207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA376070JL1Medicare UPIN