Provider Demographics
NPI:1427006444
Name:BENNETT GRUBE, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BENNETT GRUBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1044
Mailing Address - Country:US
Mailing Address - Phone:276-625-8828
Mailing Address - Fax:276-228-1776
Practice Address - Street 1:600 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1044
Practice Address - Country:US
Practice Address - Phone:276-625-8828
Practice Address - Fax:276-228-1776
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226165207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100047940Medicaid
VA1427006444Medicaid
VA015918W60Medicare PIN
VAH08222Medicare UPIN
KY7100047940Medicaid
VAP00622862Medicare PIN