Provider Demographics
NPI:1508943663
Name:GROVE, JASON J (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:GROVE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR, 3RD FLOOR RECP. A ROOM 3660A
Practice Address - Street 2:C.S. MOTT CHILDREN'S HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4252
Practice Address - Country:US
Practice Address - Phone:734-936-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP17420Medicare UPIN
MI0M52870046Medicare ID - Type Unspecified