Provider Demographics
NPI:1699780015
Name:GROTH, STEPHAN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:J
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 1:1750 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2100
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:
Practice Address - Street 1:1750 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2100
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22161174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134364Medicaid
OR134364Medicaid
ORG45456Medicare UPIN
OR105728Medicare ID - Type Unspecified