Provider Demographics
NPI: | 1891767299 |
---|---|
Name: | MCGROARTY, EDWIN T (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | EDWIN |
Middle Name: | T |
Last Name: | MCGROARTY |
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: | P.O. BOX 1563 |
Mailing Address - Street 2: | |
Mailing Address - City: | AVALON |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90704-1563 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-510-0096 |
Mailing Address - Fax: | 310-510-2938 |
Practice Address - Street 1: | 100 FALLS CANYON ROAD |
Practice Address - Street 2: | |
Practice Address - City: | AVALON |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90704-1563 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-510-0096 |
Practice Address - Fax: | 310-510-2938 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-02 |
Last Update Date: | 2023-02-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 145912 | 207Q00000X, 207Q00000X |
NM | MD2004-0369 | 207Q00000X |
KS | 04-35200 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | NM302555 | Other | MEDICARE PTAN |
NM | NM302555 | Other | MEDICARE PTAN |
NM | NM302555 | Other | MEDICARE PTAN |
AZ | 103445 | Medicare ID - Type Unspecified |