1396827358 NPI number — DR. ROBERT GROSS DO

Table of content: DR. ROBERT GROSS DO (NPI 1396827358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396827358 NPI number — DR. ROBERT GROSS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1396827358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6425 LYNCH CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ISABELLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93240-9726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-379-8630
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6425 LYNCH CANYON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ISABELLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93240-9726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-379-8630
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2006

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: 207R00000X , with the licence number:  20A7951 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5869361002 . This is a "CIGNA POS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0076650242 . This is a "PACIFICARE / SECURE HORIZONS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: OHB253 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0033089489 . This is a "HEALTHNET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 421359 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5869361004 . This is a "CIGNA HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 020A79510 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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