Basic Information
| Provider Information | |||||||||
| NPI: | 1881649754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSHONG | ||||||||
| FirstName: | TED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7687 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 402 N KEENE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738826921 | ||||||||
| FaxNumber: | 5738821154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 08/16/2011 | ||||||||
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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 | 208000000X | MD31289 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 140113001 | 01 | AR | ARKANSAS MEDICAID | OTHER | 3730 | 01 | MO | BLUE SHIELD/BLUE CHOICE | OTHER | 7509311 | 01 | MO | UNITED HEALTHCARE | OTHER | 102486 | 01 | MO | HEALTHLINK | OTHER | 200528107 | 05 | MO | MEDICAID | 2086349901 | 01 | KS | KANSAS MEDICAID | OTHER |