1104860014 NPI number — DR. TOM A GROSS DC

Table of content: DR. TOM A GROSS DC (NPI 1104860014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104860014 NPI number — DR. TOM A GROSS DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
TOM
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1104860014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 CLEMENT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HORSE SHOE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-891-8868
Provider Business Mailing Address Fax Number:
828-891-8897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4144 HAYWOOD RD
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
HORSE SHOE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-891-8868
Provider Business Practice Location Address Fax Number:
828-891-8897
Provider Enumeration Date:
06/15/2006

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: 111NN0400X , with the licence number:  NC2118 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0847B . This is a "NC STATE HEALTH PLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0847B . This is a "BLUE CROSS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890847B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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