Provider Demographics
NPI:1306838545
Name:GROVE, CHRISTOPHER ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALLEN
Last Name:GROVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-231-3414
Mailing Address - Fax:386-231-3488
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 207
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-3414
Practice Address - Fax:386-231-3488
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27210208600000X
OH35-07-3218-G208600000X
FLME 125954208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2077345Medicaid
087442Medicare ID - Type Unspecified
G82716Medicare UPIN
OHGR0874443Medicare PIN