Provider Demographics
NPI:1053713511
Name:GROUT, ELIZABETH TOEBBE (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TOEBBE
Last Name:GROUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:TOEBBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2888 E LONG LAKE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3700
Mailing Address - Country:US
Mailing Address - Phone:859-801-3679
Mailing Address - Fax:
Practice Address - Street 1:2888 E LONG LAKE RD STE 105
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3700
Practice Address - Country:US
Practice Address - Phone:248-689-1330
Practice Address - Fax:248-689-6424
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1953363A00000X
MI5601008168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100325980Medicaid
KY7100325980Medicaid