Provider Demographics
NPI:1912900291
Name:GROW, NATHANIAL D (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIAL
Middle Name:D
Last Name:GROW
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 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-354-1052
Mailing Address - Fax:812-354-8280
Practice Address - Street 1:106 W PIKE AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8750
Practice Address - Country:US
Practice Address - Phone:812-354-1052
Practice Address - Fax:812-354-8280
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044324A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100373760Medicaid
IN000000109147OtherBCBS PIN
IN100373760Medicaid
INF91539Medicare UPIN
IN100373760Medicaid