Basic Information
Provider Information | |||||||||
NPI: | 1700973583 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GROVE | ||||||||
FirstName: | CALEB | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 W CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | EL DORADO | ||||||||
State: | KS | ||||||||
PostalCode: | 670422112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3163222490 | ||||||||
FaxNumber: | 3163212916 | ||||||||
Practice Location | |||||||||
Address1: | 700 W CENTRAL AVE STE 105 | ||||||||
Address2: |   | ||||||||
City: | EL DORADO | ||||||||
State: | KS | ||||||||
PostalCode: | 670422187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3163229813 | ||||||||
FaxNumber: | 3163229806 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 06/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | T00782 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 15-01144 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 0000427308 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 200406070D | 05 | KS |   | MEDICAID |