1538130398 NPI number — DR. DAVID D GROSS M.D.

Table of content: DR. DAVID D GROSS M.D. (NPI 1538130398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538130398 NPI number — DR. DAVID D GROSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
DAVID
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1538130398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1217 N CHURCH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-234-2828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2006

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:  25MA05510200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1880403 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000616984 . This is a "IND BC PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0500085001 . This is a "AMERIHEALTH KHPE IND BC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0445341000 . This is a "AMERIHEALTH/KHPE/IND BC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3126556 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4637759 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1039710 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P395170 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: OK2158 . This is a "PHS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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