Provider Demographics
NPI:1720007404
Name:GRONLIE, TIMOTHY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:GRONLIE
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 1:551 N. HILLSIDE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4926
Mailing Address - Country:US
Mailing Address - Phone:316-685-1367
Mailing Address - Fax:316-685-9388
Practice Address - Street 1:550 N HILLSIDE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-2900
Practice Address - Fax:316-962-7815
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04308252085R0202X, 2085R0204X, 2085U0001X
KS04-308252085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200385940CMedicaid
KS105646OtherBCBS
106166Medicare PIN
KS105646OtherBCBS