Healthcare Provider Details

I. General information

NPI: 1609040088
Provider Name (Legal Business Name): JASON R GROVE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 101
MISHAWAKA IN
46545-1464
US

IV. Provider business mailing address

707 CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6800
  • Fax: 574-335-0772
Mailing address:
  • Phone: 574-335-8700
  • Fax: 574-335-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07001058A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003447
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: