1093017568 NPI number — MRS. MIRIAM REBECCA GROSS MS, RD

Table of content: MRS. MIRIAM REBECCA GROSS MS, RD (NPI 1093017568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093017568 NPI number — MRS. MIRIAM REBECCA GROSS MS, RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
MIRIAM
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COHEN
Provider Other First Name:
MIRIAM
Provider Other Middle Name:
REBECCA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093017568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1615 CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08904-3708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-633-2260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08904-3708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-633-2260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2010

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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