Provider Demographics
NPI:1932153236
Name:GROVE, JEROME JULIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JULIAN
Last Name:GROVE
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 1:20950 N TATUM BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4204
Mailing Address - Country:US
Mailing Address - Phone:480-222-7246
Mailing Address - Fax:480-222-7271
Practice Address - Street 1:20950 N TATUM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4204
Practice Address - Country:US
Practice Address - Phone:480-222-7246
Practice Address - Fax:480-222-7271
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL15479R174400000X
AZ37166208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAI16742Medicare UPIN