Provider Demographics
NPI:1538136932
Name:GROVE, LUCIAN Y JR (MD)
Entity Type:Individual
Prefix:
First Name:LUCIAN
Middle Name:Y
Last Name:GROVE
Suffix:JR
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 1:1935 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3109
Mailing Address - Country:US
Mailing Address - Phone:540-302-0190
Mailing Address - Fax:540-302-0191
Practice Address - Street 1:1935 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3109
Practice Address - Country:US
Practice Address - Phone:540-302-0190
Practice Address - Fax:540-302-0191
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005884322Medicaid
VAC36546Medicare UPIN
VA005884322Medicaid