Provider Demographics
NPI:1649451907
Name:GROS VENTRE OB/GYN, LLP
Entity type:Organization
Organization Name:GROS VENTRE OB/GYN, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-734-1005
Mailing Address - Street 1:PO BOX 3306
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3306
Mailing Address - Country:US
Mailing Address - Phone:307-734-1005
Mailing Address - Fax:307-734-1065
Practice Address - Street 1:555 E BROADWAY AVE STE 108
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-734-1005
Practice Address - Fax:307-734-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty