Provider Demographics
NPI:1366531451
Name:GROVES, CHARLES A (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:GROVES
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 1:8900 SE 165TH MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5884
Mailing Address - Country:US
Mailing Address - Phone:352-674-5000
Mailing Address - Fax:
Practice Address - Street 1:8900 SE 165TH MULBERRY LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5884
Practice Address - Country:US
Practice Address - Phone:352-674-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200020550Medicaid
IN000000295923OtherANTHEM
IN000000295923OtherUNICARE
IN352146688OtherTAX ID
INE99824Medicare UPIN
IN200020550Medicaid