Provider Demographics
NPI:1336191170
Name:GRONBACH, KORT M (MD)
Entity Type:Individual
Prefix:
First Name:KORT
Middle Name:M
Last Name:GRONBACH
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 1:568 S CLEVELAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8959
Mailing Address - Country:US
Mailing Address - Phone:614-895-3344
Mailing Address - Fax:614-895-3344
Practice Address - Street 1:568 S CLEVELAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8959
Practice Address - Country:US
Practice Address - Phone:614-895-3344
Practice Address - Fax:614-895-3344
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086736207L00000X, 208VP0014X
OH35.086736208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2653285Medicaid
OH4193572Medicare PIN