Grootegoed, Russell A.

Grootegoed, Russell A. is an sole proprietor health care provider with primary practice located at 601 W 9Th St , San Pedro CA 90731-3107. He recently has 2 registered licenses in different health care specialties including Podiatric Medicine & Surgery Service Providers / Foot & Ankle Surgery, Suppliers / Prosthetic/Orthotic Supplier. Podiatric Medicine & Surgery Service Providers / Foot & Ankle Surgery is his primary health care specialty. Grootegoed, Russell A. can be contacted via phone (310) 833-3583.

Contact Information

Primary practice address
601 W 9Th St San Pedro CA 90731-3107
Phone: (310) 833-3583
Fax: (310) 833-1976
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Podiatric Medicine & Surgery Service Providers / Foot & Ankle Surgery 213ES0103X E2064 California
Suppliers / Prosthetic/Orthotic Supplier 335E00000X E2064 California

Profile Details

NPI number 1194767921
LBN Legal business name Grootegoed, Russell A.
Credentials Doctor of Podiatric Medicine (DPM)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Jun 13th, 2006
Last updated Apr 11th, 2008 - about 16 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1194767921 NPPES
California Other 953239247 BLUE CROSS
California MEDICAID 000E2064000 BLUE CROSS

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