Basic Information
| Provider Information | |||||||||
| NPI: | 1932426566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRODOFSKY | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BALA AVE STE 418 | ||||||||
| Address2: | |||||||||
| City: | BALA CYNWYD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190043207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153662803 | ||||||||
| FaxNumber: | 2673377950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BALA AVE STE 418 | ||||||||
| Address2: | |||||||||
| City: | BALA CYNWYD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190043207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153662803 | ||||||||
| FaxNumber: | 2673377950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 12/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2019 | ||||||||
| NPIReactivationDate: | 04/05/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/26/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD451221 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | MD451221 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.