Provider Demographics
NPI:1639386329
Name:GROVE, KELLY RENEE (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:GROVE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:121 TEUFEN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7076
Mailing Address - Country:US
Mailing Address - Phone:856-287-9725
Mailing Address - Fax:
Practice Address - Street 1:703 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5239
Practice Address - Country:US
Practice Address - Phone:252-633-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
DEC2-0009772208000000X
NC201300321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program