Provider Demographics
NPI:1497913834
Name:GROSE, JARED DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:DALE
Last Name:GROSE
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 1:2773 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3857
Mailing Address - Country:US
Mailing Address - Phone:541-207-0910
Mailing Address - Fax:541-738-2596
Practice Address - Street 1:2773 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3857
Practice Address - Country:US
Practice Address - Phone:541-207-0910
Practice Address - Fax:541-738-2596
Is Sole Proprietor?:No
Enumeration Date:2008-05-31
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD157444207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500648433Medicaid
ORR165959Medicare PIN