Provider Demographics
NPI:1891978490
Name:MARTIN H GROTHEER MD
Entity Type:Organization
Organization Name:MARTIN H GROTHEER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-542-6644
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74355-1328
Mailing Address - Country:US
Mailing Address - Phone:918-542-6644
Mailing Address - Fax:918-542-6167
Practice Address - Street 1:10 S TREATY RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5330
Practice Address - Country:US
Practice Address - Phone:918-542-6644
Practice Address - Fax:918-542-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200008360AMedicaid
OK100522033Medicare PIN