1285635805 NPI number — SHELDON WARREN GROSS M.D.

Table of content: SHELDON WARREN GROSS M.D. (NPI 1285635805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285635805 NPI number — SHELDON WARREN GROSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
SHELDON
Provider Middle Name:
WARREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROSS
Provider Other First Name:
S.
Provider Other Middle Name:
WARREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1285635805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 PRESIDENTIAL BLVD
Provider Second Line Business Mailing Address:
UNIT 217
Provider Business Mailing Address City Name:
BALA CYNWYD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19004-1217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-231-4774
Provider Business Mailing Address Fax Number:
856-231-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 PRESIDENTIAL BLVD
Provider Second Line Business Practice Location Address:
UNIT 217
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004-1217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-661-5473
Provider Business Practice Location Address Fax Number:
856-661-5470
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  25MA05827700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD008874E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4603001 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com