Basic Information
| Provider Information | |||||||||
| NPI: | 1285994236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROAG | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | DINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEISS | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | DINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 3013409027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 IMPERIAL DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217406555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106659098 | ||||||||
| FaxNumber: | 3016659096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R200366 | MD | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 367A00000X | R200366 | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.