Basic Information
Provider Information | |||||||||
NPI: | 1598747321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GROOS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERS | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 UNIVERSITY AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503142355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152481447 | ||||||||
FaxNumber: | 5152481440 | ||||||||
Practice Location | |||||||||
Address1: | 1212 PLEASANT ST | ||||||||
Address2: | SUITE 300 | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503091453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152418923 | ||||||||
FaxNumber: | 5152418728 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 07/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35505 | IA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 209917905 | 05 | MO |   | MEDICAID | 1598747321 | 05 | IA |   | MEDICAID | 175150018 | 01 |   | MEDICARE | OTHER | 9263738 | 05 | CA |   | MEDICAID |