1265752927 NPI number — DAVID G. GROSS, D.O., P.C.

Table of content: (NPI 1265752927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265752927 NPI number — DAVID G. GROSS, D.O., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID G. GROSS, D.O., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1265752927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 S LAKE PARK AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
HOBART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46342-6790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-947-4410
Provider Business Mailing Address Fax Number:
219-942-7136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S LAKE PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
HOBART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46342-6790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-947-4410
Provider Business Practice Location Address Fax Number:
219-942-7136
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-769-8989

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  50004042A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 50004042A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000105018 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100169420 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com