Provider Demographics
NPI:1487703864
Name:GROTH, TRAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:GROTH
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 1:840 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3586
Mailing Address - Country:US
Mailing Address - Phone:414-805-5540
Mailing Address - Fax:414-805-7878
Practice Address - Street 1:840 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3586
Practice Address - Country:US
Practice Address - Phone:414-805-5540
Practice Address - Fax:414-805-7878
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47980020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487703864Medicaid
WI736011744Medicare PIN
WI1487703864Medicaid