Provider Demographics
NPI:1205681327
Name:GROOME, MITCHELL JOSEPH
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JOSEPH
Last Name:GROOME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6268 SKYVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-2434
Mailing Address - Country:US
Mailing Address - Phone:901-461-5404
Mailing Address - Fax:
Practice Address - Street 1:7691 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3904
Practice Address - Country:US
Practice Address - Phone:901-516-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN148849367500000X
TN238751163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered