Provider Demographics
NPI:1710921267
Name:GROVES, MARILYN S (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:GROVES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:S
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9365
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:2600 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1533
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001259A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00106755OtherRAILROAD MEDICARE PIN
000000533123OtherANTHEM PIN
IN200361200Medicaid
IN200361200Medicaid
226830XMedicare PIN