Provider Demographics
NPI:1902192941
Name:GROOMS, BRYAN D (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:GROOMS
Suffix:
Gender:M
Credentials:DO
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 155
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45697-0155
Mailing Address - Country:US
Mailing Address - Phone:937-695-0770
Mailing Address - Fax:888-230-8394
Practice Address - Street 1:PO BOX 155
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45697-0155
Practice Address - Country:US
Practice Address - Phone:937-695-0770
Practice Address - Fax:888-230-8394
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP627207Q00000X
OH34.010744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0081452Medicaid