Provider Demographics
NPI:1013926393
Name:GROW, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GROW
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 1:144 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:801-463-7415
Mailing Address - Fax:
Practice Address - Street 1:5475 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:801-479-2376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6884270-1205207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN886605000Medicaid
MN886605000Medicaid
MN930002553Medicare ID - Type Unspecified