Provider Demographics
NPI:1407832777
Name:GROENENDAAL, GENE A (DO)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:A
Last Name:GROENENDAAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 W 26TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-3064
Mailing Address - Country:US
Mailing Address - Phone:814-480-7760
Mailing Address - Fax:814-480-7761
Practice Address - Street 1:2861 W 26TH ST STE 2
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-3064
Practice Address - Country:US
Practice Address - Phone:814-480-7760
Practice Address - Fax:814-480-7761
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080340OtherMEDICARE
1621512OtherHIGHMARK
I08552OtherUPIN