Provider Demographics
NPI:1912193640
Name:GROSVENOR, STEPHANIE WISE (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:WISE
Last Name:GROSVENOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 772437
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2437
Mailing Address - Country:US
Mailing Address - Phone:317-575-7304
Mailing Address - Fax:317-575-7333
Practice Address - Street 1:10228 DUPONT CIRCLE DR E STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1611
Practice Address - Country:US
Practice Address - Phone:260-222-7401
Practice Address - Fax:260-209-5956
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI1132870207V00000X
IN02006694A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology