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General NPI Number Information
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NPI Number | 1427006444
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Entity Type | Individual
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Provider Name | JENNIFER LYNN BENNETT GRUBE MD
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Gender | Female
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 02/27/2012
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Provider Practice Location Address
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Address Line | 600 W RIDGE RD
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City | WYTHEVILLE
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State | VA
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Zip | 24382-1044
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Country | US
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Telephone | 276-625-8828
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Fax | 276-228-1776
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Provider Business Mailing Address
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Address Line | 600 W RIDGE RD
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City | WYTHEVILLE
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State | VA
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Zip | 24382-1044
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Country | US
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Telephone | 276-625-8828
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Fax | 276-228-1776
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101226165
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 0101226165
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License Number State | VA
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