Provider Demographics
NPI:1396716163
Name:GROLL, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:GROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1028 S KIRKWOOD RD STE A
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7222
Mailing Address - Country:US
Mailing Address - Phone:314-441-5609
Mailing Address - Fax:314-288-0519
Practice Address - Street 1:1900 STATE ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1116
Practice Address - Country:US
Practice Address - Phone:618-826-4581
Practice Address - Fax:318-826-5152
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J11174400000X
IL036-094904207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110115438Medicare PIN
E87756Medicare UPIN
IL212936Medicare PIN
MO000050148Medicare PIN