1578564605 NPI number — SUSAN A GROSS MD

Table of content: SUSAN A GROSS MD (NPI 1578564605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578564605 NPI number — SUSAN A GROSS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
SUSAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1578564605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3020 N MCCORD RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-843-8160
Provider Business Mailing Address Fax Number:
419-841-7038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 N MCCORD RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43615-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-843-8160
Provider Business Practice Location Address Fax Number:
419-841-7038
Provider Enumeration Date:
08/10/2005

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:  35067804 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04-03000 . This is a "UHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0638005 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 29556773-003 . This is a "MMO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000141247 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0163433 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11062 . This is a "HPM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 01991 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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