Healthcare Provider Details

I. General information

NPI: 1194088963
Provider Name (Legal Business Name): JACQUELYN E. GREV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 22ND ST
SIOUX FALLS SD
57105
US

IV. Provider business mailing address

1600 W 22ND ST
SIOUX FALLS SD
57105-1521
US

V. Phone/Fax

Practice location:
  • Phone: 605-312-1000
  • Fax:
Mailing address:
  • Phone: 605-312-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042.0013120
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56560
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number10846
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierENROLLED
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
IdentifierENROLLED
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: