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
StateLicense IDTaxonomies
CA145912207Q00000X, 207Q00000X
NMMD2004-0369207Q00000X
KS04-35200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM302555OtherMEDICARE PTAN
NMNM302555OtherMEDICARE PTAN
NMNM302555OtherMEDICARE PTAN
AZ103445Medicare ID - Type Unspecified