Basic Information
| Provider Information | |||||||||
| NPI: | 1750378022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROGAN | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636961 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815098 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704429463 | ||||||||
| FaxNumber: | 2704422241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
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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 | 208600000X | 20054 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036093089 | IL | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00976650 | 01 | KY | RAIL ROAD MEDICARE | OTHER | 04705710211 | 05 | IL | MEDICAID | 64200546 | 05 | KY | MEDICAID |