Provider Demographics
NPI:1154587533
Name:GROGAN, KIM RUTISHAUSER (PT)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:RUTISHAUSER
Last Name:GROGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KIM
Other - Middle Name:ALISON
Other - Last Name:RUTISHAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:262 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3274
Mailing Address - Country:US
Mailing Address - Phone:844-342-1753
Mailing Address - Fax:262-372-1753
Practice Address - Street 1:262 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3274
Practice Address - Country:US
Practice Address - Phone:844-342-1753
Practice Address - Fax:262-372-5605
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003699225100000X
MA23562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076572Medicare PIN