Provider Demographics
NPI:1609040088
Name:GROVE, JASON R (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:GROVE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:611 E DOUGLAS RD STE 101
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6800
Practice Address - Fax:574-335-0772
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003447213ES0103X
IN07001058A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000592921OtherBCBS BMG SCHWARTZ
IN000000591890OtherBCBS BMG LAPORTE
IN738460026OtherMEDICARE PIN
ININ1933041OtherMEDICARE PIN
IN000000591888OtherBCBS BMG MAIN STREET
IN000000592923OtherBCBS BMG IRELAND
IN000000710624OtherBCBS BMG BREMEN
INP00656770OtherRR MEDICARE
IN000000630279OtherBCBS BMG PORTAGE
IN200912030Medicaid
INP00656770OtherRR MEDICARE
IN236040H6Medicare PIN