Individual
MR. MARK LESLIE GROGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
401 BAPTIST DR, SUITE 306, MADISON, MS 39110-2009
(601) 607-7204
(601) 607-7430
Mailing address
401 BAPTIST DR, SUITE 306, MADISON, MS 39110-2009
(601) 607-7204
(601) 607-7430
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA4334
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0220392
—
MS
01
—
640881013
TAX ID
MS
Enumeration date
01/11/2011
Last updated
01/11/2011
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