Provider Demographics
NPI:1811977028
Name:DE GROEN, PIET C (MD)
Entity type:Individual
Prefix:
First Name:PIET
Middle Name:C
Last Name:DE GROEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETRUS
Other - Middle Name:C
Other - Last Name:DE GROEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28044207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN339526000Medicaid
MN110065466Medicare ID - Type UnspecifiedRAILROAD
MN339526000Medicaid
MN100000321Medicare ID - Type Unspecified