1487674008 NPI number — MR. JOHN DONELSON GROVE III CLINICAL SOCIAL WORK

Table of content: MR. JOHN DONELSON GROVE III CLINICAL SOCIAL WORK (NPI 1487674008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487674008 NPI number — MR. JOHN DONELSON GROVE III CLINICAL SOCIAL WORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROVE
Provider First Name:
JOHN
Provider Middle Name:
DONELSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
CLINICAL SOCIAL WORK
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:
1487674008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 RUSKIN DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTOONA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-215-3999
Provider Business Mailing Address Fax Number:
814-940-6308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 RUSKIN DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTOONA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-215-3999
Provider Business Practice Location Address Fax Number:
814-940-6308
Provider Enumeration Date:
07/19/2006

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: 1041C0700X , with the licence number:  CW013302 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000792941 . This is a "HEALTH INSURANCE - B/C; B" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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