Basic Information
| Provider Information | |||||||||
| NPI: | 1720007404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRONLIE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 551 N. HILLSIDE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166851367 | ||||||||
| FaxNumber: | 3166859388 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169622900 | ||||||||
| FaxNumber: | 3169627815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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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 | 2085R0202X | 0430825 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 0430825 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 04-30825 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 04-30825 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 200385940C | 05 | KS | MEDICAID | 105646 | 01 | KS | BCBS | OTHER |