Provider Demographics
NPI:1750378022
Name:GROGAN, EDWIN L (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:L
Last Name:GROGAN
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-981-5098
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:1532 LONE OAK RD
Practice Address - Street 2:SUITE 235
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7913
Practice Address - Country:US
Practice Address - Phone:270-442-9463
Practice Address - Fax:270-442-2241
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20054208600000X
IL036093089208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00976650OtherRAIL ROAD MEDICARE
IL04705710211Medicaid
KY64200546Medicaid
KYP00976650OtherRAIL ROAD MEDICARE
IL04705710211Medicaid
KYK003300Medicare PIN