Provider Demographics
NPI:1902884950
Name:GRONBORG, GERALD E (DPM)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:E
Last Name:GRONBORG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BEALE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1705
Mailing Address - Country:US
Mailing Address - Phone:814-946-1075
Mailing Address - Fax:814-946-4076
Practice Address - Street 1:2727 BEALE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1705
Practice Address - Country:US
Practice Address - Phone:814-946-1075
Practice Address - Fax:814-946-4076
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003442L213EP1101X, 213ES0103X, 213E00000X, 213ER0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012762560012Medicaid
PA5166987OtherPPNI
PA826758OtherBLUE SHIELD GROUP
PA000706203OtherKEYSTONE HEALTH PLAN
PACC2226OtherRR MEDICARE GROUP
PAP 54229714OtherMULTIPLAN
PA0012762560009Medicaid
PA0012762560010Medicaid
PA0857830000OtherPPO PROGRAM INDEPENDENCE
PA200069OtherUPMC
PA2805196OtherAETNA HMO QPOS
PA21128765012OtherBEECH STREET
PA480013965OtherRR MEDICARE INDIVIDUAL
PA1022107OtherGATEWAY
PA7318023OtherMAMSI
PAGR706203OtherBLUE SHIELD INDIVIDUAL
PA000000060525OtherUNISON
PA0012762560010Medicaid
PAGR706203OtherBLUE SHIELD INDIVIDUAL
PA21128765012OtherBEECH STREET
PA2805196OtherAETNA HMO QPOS