Provider Demographics
NPI:1912765488
Name:GROTHE, SUSAN K
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:GROTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10679 83RD ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4515
Mailing Address - Country:US
Mailing Address - Phone:952-207-4899
Mailing Address - Fax:
Practice Address - Street 1:11200 STILLWATER BLVD N STE 101
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8625
Practice Address - Country:US
Practice Address - Phone:952-207-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN410794261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center