Provider Demographics
NPI:1538850318
Name:GROOMS, AUSTEN NICKLAUS (DO)
Entity type:Individual
Prefix:DR
First Name:AUSTEN
Middle Name:NICKLAUS
Last Name:GROOMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 WEST 13 MILE ROAD, LL - SOUTH CLINIC
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 WEST 13 MILE ROAD, LL - SOUTH CLINIC
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-551-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151016217208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No208000000XAllopathic & Osteopathic PhysiciansPediatrics