Provider Demographics
NPI:1891788519
Name:GROLL, JEROME E (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:E
Last Name:GROLL
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 1:34445 KING STREET ROW
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-4787
Mailing Address - Country:US
Mailing Address - Phone:302-645-2833
Mailing Address - Fax:978-327-7891
Practice Address - Street 1:34445 KING STREET ROW
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4787
Practice Address - Country:US
Practice Address - Phone:302-645-2833
Practice Address - Fax:978-327-7891
Is Sole Proprietor?:No
Enumeration Date:2005-08-28
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000026301Medicaid
DE0000026301Medicaid
G00540Medicare ID - Type Unspecified