Provider Demographics
NPI:1801020078
Name:GROMAN, JOEL (PA)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:GROMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19640
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9640
Mailing Address - Country:US
Mailing Address - Phone:217-545-5117
Mailing Address - Fax:217-545-4912
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:STE 6W100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-5117
Practice Address - Fax:217-545-4912
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207236012Medicare PIN