Provider Demographics
NPI:1871678144
Name:GROOM, GLENN CURTIS (PA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CURTIS
Last Name:GROOM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2549
Practice Address - Country:US
Practice Address - Phone:219-836-5800
Practice Address - Fax:219-836-3048
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004940207P00000X, 363A00000X
IN10000975A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q73277Medicare UPIN
MIMI1609059Medicare PIN