Provider Demographics
NPI:1124024914
Name:GROOM, JEFFREY A (PHD, CRNA)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:GROOM
Suffix:
Gender:M
Credentials:PHD, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 NE 93RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2854
Mailing Address - Country:US
Mailing Address - Phone:305-348-7725
Mailing Address - Fax:
Practice Address - Street 1:11200 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-0001
Practice Address - Country:US
Practice Address - Phone:305-348-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1322612367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered