1861584682 NPI number — BRANDON T GROVER D.O.

Table of content: BRANDON T GROVER D.O. (NPI 1861584682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861584682 NPI number — BRANDON T GROVER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROVER
Provider First Name:
BRANDON
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1861584682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1836 SOUTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CROSSE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54601-5429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-782-7300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1836 SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-782-7300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  02002718A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 51586-021 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 34.009779 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)