Provider Demographics
NPI:1912016064
Name:GROVE, KATHLEEN LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LOUISE
Last Name:GROVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-335-0185
Practice Address - Fax:573-335-0793
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086294207L00000X
MO2005008372207LC0200X, 207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
697359OtherHEALTHLINK
MO105181OtherBLUE CROSS BLUE SHIELD
IL036086294Medicaid
MO207336405Medicaid
697359OtherHEALTHLINK
IL036086294Medicaid