Basic Information
| Provider Information | |||||||||
| NPI: | 1609878560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROFF | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2819 DENNY AVE. | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287623466 | ||||||||
| FaxNumber: | 2287626349 | ||||||||
| Practice Location | |||||||||
| Address1: | 2819 DENNY AVE. | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287623466 | ||||||||
| FaxNumber: | 2287626349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 07078 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00115070 | 05 | MS | MEDICAID | 5352041 | 01 | MS | AETNA PROVIDER ID# | OTHER |