Provider Demographics
NPI:1073678561
Name:JAN C GROMADA DO FACOOG PLLC
Entity type:Organization
Organization Name:JAN C GROMADA DO FACOOG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROMADA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-245-9011
Mailing Address - Street 1:420 W NEPESSING ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2150
Mailing Address - Country:US
Mailing Address - Phone:810-245-9011
Mailing Address - Fax:810-245-9012
Practice Address - Street 1:420 W NEPESSING ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2150
Practice Address - Country:US
Practice Address - Phone:810-245-9011
Practice Address - Fax:810-245-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006098207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101006098OtherLICENSE
MI5101006098OtherLICENSE
MIAG6460529OtherDEA
MIE26064Medicare UPIN