Provider Demographics
NPI:1467452391
Name:GROENEVELD, JOHN RAY (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RAY
Last Name:GROENEVELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:906-776-9040
Practice Address - Fax:906-774-7279
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI406754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1994486Medicaid
WI31491800Medicaid
MIP01692639OtherRAILROAD MEDICARE
WI31491800Medicaid
MI1994486Medicaid
MI233885Medicare Oscar/Certification