1609040088 NPI number — JASON R GROVE DPM

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609040088 NPI number — JASON R GROVE DPM

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GROVE

Provider First Name:

JASON

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DPM

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1609040088

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/15/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

707 CEDAR ST STE 200

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SOUTH BEND

Provider Business Mailing Address State Name:

IN

Provider Business Mailing Address Postal Code:

46617-2057

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

574-335-8700

Provider Business Mailing Address Fax Number:

574-335-0760

Provider First Line Business Practice Location Address:

611 E DOUGLAS RD STE 101

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MISHAWAKA

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

46545-1464

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

574-335-6800

Provider Business Practice Location Address Fax Number:

574-335-0772

Provider Enumeration Date:

04/17/2008

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 213ES0103X , with the licence number:  36.003447 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 213E00000X , with the licence number: 07001058A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000000592921 . This is a "BCBS BMG SCHWARTZ" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 000000591890 . This is a "BCBS BMG LAPORTE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 738460026 . This is a "MEDICARE PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: IN1933041 . This is a "MEDICARE PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 000000591888 . This is a "BCBS BMG MAIN STREET" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 000000592923 . This is a "BCBS BMG IRELAND" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 000000710624 . This is a "BCBS BMG BREMEN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: P00656770 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 000000630279 . This is a "BCBS BMG PORTAGE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 200912030 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".