Provider Demographics
NPI:1841212701
Name:GROMADA, JAN C (DO)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:C
Last Name:GROMADA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LAKE NEPRESSING RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446
Mailing Address - Country:US
Mailing Address - Phone:810-245-9011
Mailing Address - Fax:
Practice Address - Street 1:420 LAKE NEPESSING RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2961
Practice Address - Country:US
Practice Address - Phone:810-245-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJG006098207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114737651Medicaid
MI114901620OtherMOLINA
MI141205OtherCARE CHOICES
MI1015855OtherMCLAREN HEALTH PLAN
MI1G00026OtherHEALTH PLAN OF MICHIGAN
MIC1522OtherMCARE HMO
MI1654410124OtherBCBS
MI114901620OtherMOLINA
MIP15570001Medicare PIN