Basic Information
| Provider Information | |||||||||
| NPI: | 1891978490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTIN H GROTHEER MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1328 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743551328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185426644 | ||||||||
| FaxNumber: | 9185426167 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 S TREATY RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743545330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185426644 | ||||||||
| FaxNumber: | 9185426167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | OAKLEY | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9185426644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10117 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200008360A | 05 | OK | MEDICAID |