Provider Demographics
NPI:1710022447
Name:GROVENBURG, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:GROVENBURG
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 1:5 GOLDEN LANE
Mailing Address - Street 2:
Mailing Address - City:KERHONKSON
Mailing Address - State:NY
Mailing Address - Zip Code:12446
Mailing Address - Country:US
Mailing Address - Phone:845-626-3424
Mailing Address - Fax:845-626-4627
Practice Address - Street 1:5 GOLDEN LN
Practice Address - Street 2:
Practice Address - City:KERHONKSON
Practice Address - State:NY
Practice Address - Zip Code:12446-1609
Practice Address - Country:US
Practice Address - Phone:845-626-3424
Practice Address - Fax:845-626-4627
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181048-1207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01805201Medicaid
NY01805201Medicaid
NYF62465Medicare UPIN