Provider Demographics
NPI:1881649754
Name:GROSHONG, TED (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:GROSHONG
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:402 N KEENE ST
Practice Address - Street 2:STE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6986
Practice Address - Country:US
Practice Address - Phone:573-882-6921
Practice Address - Fax:573-882-1154
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD31289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140113001OtherARKANSAS MEDICAID
MO3730OtherBLUE SHIELD/BLUE CHOICE
MO7509311OtherUNITED HEALTHCARE
MO102486OtherHEALTHLINK
MO200528107Medicaid
KS2086349901OtherKANSAS MEDICAID
MO200528107Medicaid
MO083010635Medicare PIN
KS2086349901OtherKANSAS MEDICAID