Provider Demographics
NPI:1710077110
Name:GRUBBS, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:GRUBBS
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 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-7653
Mailing Address - Fax:270-575-8359
Practice Address - Street 1:2603 KENTUCKY AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3814
Practice Address - Country:US
Practice Address - Phone:270-415-4800
Practice Address - Fax:270-415-4801
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64261993Medicaid
C63122Medicare UPIN
KYK038311Medicare PIN
KYK038310Medicare PIN