Provider Demographics
NPI:1255350542
Name:GROTH, KEVIN P (DC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:P
Last Name:GROTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 HERITAGE BLVD., SUITE 203
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669
Mailing Address - Country:US
Mailing Address - Phone:608-786-3670
Mailing Address - Fax:608-786-3672
Practice Address - Street 1:1540 HERITAGE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669
Practice Address - Country:US
Practice Address - Phone:608-786-3670
Practice Address - Fax:608-786-3672
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4109-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00600195OtherMEDICARE RAILROAD
WI38959600Medicaid
WI000470470Medicare PIN
WIP00600195OtherMEDICARE RAILROAD
WIU93868Medicare UPIN
WIU93868Medicare UPIN