Provider Demographics
NPI:1265665178
Name:GRONEWOLD, BRIAN MICHAEL (MED,ATC, LAT, CSCS)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GRONEWOLD
Suffix:
Gender:M
Credentials:MED,ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6450
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1541
Practice Address - Country:US
Practice Address - Phone:251-665-8200
Practice Address - Fax:251-665-8210
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL9942255A2300X
ALPA.1896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer