Provider Demographics
NPI:1932426566
Name:GRODOFSKY, SAMUEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROBERT
Last Name:GRODOFSKY
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 1:1 BALA AVE STE 418
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-3207
Mailing Address - Country:US
Mailing Address - Phone:215-366-2803
Mailing Address - Fax:267-337-7950
Practice Address - Street 1:1 BALA AVE STE 418
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3207
Practice Address - Country:US
Practice Address - Phone:215-366-2803
Practice Address - Fax:267-337-7950
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2019-12-26
Deactivation Date:2019-03-23
Deactivation Code:
Reactivation Date:2019-04-05
Provider Licenses
StateLicense IDTaxonomies
PAMD451221207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine