1740276351 NPI number — DR. CHARLES GROSS DPM

Table of content: DR. CHARLES GROSS DPM (NPI 1740276351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740276351 NPI number — DR. CHARLES GROSS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740276351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 HIGH RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAMFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06905-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-322-4199
Provider Business Mailing Address Fax Number:
203-329-8017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 HIGH RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06905-3813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-322-4199
Provider Business Practice Location Address Fax Number:
203-329-8017
Provider Enumeration Date:
09/20/2005

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: 213E00000X , with the licence number:  482 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0212695002 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 607508 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P383730 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 030000482CT01 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3V1076 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004099017 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27-00926 . This is a "EVERCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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