Basic Information
| Provider Information | |||||||||
| NPI: | 1801328695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROTT | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 S CREASY LN STE 100A | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479052908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657016451 | ||||||||
| FaxNumber: | 7654205801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 11020205A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207R00000X | MED-RES-LIC-58231 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208VP0014X | 036156733 | IL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 01083529A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.