Healthcare Provider Details

I. General information

NPI: 1932153236
Provider Name (Legal Business Name): JEROME JULIAN GROVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20950 N TATUM BLVD STE 100
PHOENIX AZ
85050-4204
US

IV. Provider business mailing address

20950 N TATUM BLVD STE 100
PHOENIX AZ
85050-4204
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-7246
  • Fax: 480-222-7271
Mailing address:
  • Phone: 480-222-7246
  • Fax: 480-222-7271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL15479R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number37166
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: