Provider Demographics
NPI:1942203419
Name:GROEGER, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:GROEGER
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732
Practice Address - Country:US
Practice Address - Phone:605-717-6431
Practice Address - Fax:605-719-6471
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
100936Medicare PIN
A73138Medicare UPIN