1700801875 NPI number — ROBERT A GROSS MD.,PHD

Table of content: ROBERT A GROSS MD.,PHD (NPI 1700801875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700801875 NPI number — ROBERT A GROSS MD.,PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
ROBERT
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD.,PHD
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:
1700801875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 278984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14627-8984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-341-7420
Provider Business Mailing Address Fax Number:
585-756-2311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 WESTFALL RD
Provider Second Line Business Practice Location Address:
BLDG C, STE 215
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14618-2638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-341-7420
Provider Business Practice Location Address Fax Number:
585-756-2311
Provider Enumeration Date:
07/12/2006

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: 2084V0102X , with the licence number:  197683 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01616339 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDA946 . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010197683 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00040114001 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5059134 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6325 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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