Healthcare Provider Details

I. General information

NPI: 1639273311
Provider Name (Legal Business Name): DIANE GROVE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N CLARE AVE
HARRISON MI
48625-9194
US

IV. Provider business mailing address

815 N CLARE AVE
HARRISON MI
48625-9194
US

V. Phone/Fax

Practice location:
  • Phone: 989-539-4434
  • Fax: 989-539-4480
Mailing address:
  • Phone: 989-539-4434
  • Fax: 989-539-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberDG004869
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: