Provider Demographics
NPI:1528351657
Name:GROTH, TRAVIS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:JOHN
Last Name:GROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:266 JOULE ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2422
Practice Address - Country:US
Practice Address - Phone:865-984-3864
Practice Address - Fax:865-380-4095
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2017-05-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNDO0000002422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ006907Medicaid
TNQ006907Medicaid