=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821055930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER L GROVES, MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 07/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W LANCASTER AVE SUITE 215
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19301-1751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-647-1204
-----------------------------------------------------
Fax | 610-647-1240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 W LANCASTER AVE SUITE 215
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19301-1751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-647-1204
-----------------------------------------------------
Fax | 610-647-1240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROGER L GROVES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-647-1204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD033248L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------