Basic Information
| Provider Information | |||||||||
| NPI: | 1063648541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROVER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 GUTHRIE SQ | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708885858 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 GUTHRIE DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148303696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6079377451 | ||||||||
| FaxNumber: | 6079377860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ND451410 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | MD451410 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 03853138 | 05 | NY | MEDICAID | 1029752450001 | 05 | PA | MEDICAID |