Provider Demographics
NPI:1770513210
Name:GROTE, RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:GROTE
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 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-623-4077
Mailing Address - Fax:417-623-5171
Practice Address - Street 1:702 E 34TH STREET
Practice Address - Street 2:STE 203
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-523-4077
Practice Address - Fax:417-623-5171
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1C31208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11782OtherANTHEM
MO11782OtherANTHEM