Provider Demographics
NPI:1659391704
Name:GROVER, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GROVER
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 1:589 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5056
Mailing Address - Country:US
Mailing Address - Phone:801-429-2000
Mailing Address - Fax:801-429-2001
Practice Address - Street 1:589 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5056
Practice Address - Country:US
Practice Address - Phone:801-429-2000
Practice Address - Fax:801-429-2001
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2634241205207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT37767OtherCHIP MEDICAID/PEHP
UT5935032OtherAETNA
UT870515716GR1OtherEMIA
UT0101858OtherUNITED HEALTH CARE
UT107007185101OtherSELECT HEALTH
UT870515716OtherBEECH STREET CORP
UT870515716004Medicaid
UT870515716018Medicaid
UTD0282OtherMEDICAID LICENSE #
UT870515716OtherGEHA
UT870515716018Medicaid
UT870515716GR1OtherEMIA