Provider Demographics
NPI:1124072855
Name:GROTH, GREGORY D (RPAC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:GROTH
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8470 INDIAN FALLS RD
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-9641
Mailing Address - Country:US
Mailing Address - Phone:585-762-9292
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6800
Practice Address - Country:US
Practice Address - Phone:716-626-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005566OtherLICENSE