1659563344 NPI number — MARY SOBNOSKY GROSS MS, RD, LDN

Table of content: MARY SOBNOSKY GROSS MS, RD, LDN (NPI 1659563344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659563344 NPI number — MARY SOBNOSKY GROSS MS, RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
MARY
Provider Middle Name:
SOBNOSKY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROSS
Provider Other First Name:
MARY
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD, LDN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1659563344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
416 CONSTITUTION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27705-2853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-382-2819
Provider Business Mailing Address Fax Number:
919-382-2029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 CONSTITUTION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27705-2853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-382-2819
Provider Business Practice Location Address Fax Number:
919-382-2029
Provider Enumeration Date:
08/16/2007

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: 133N00000X , with the licence number:  L000615 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: L000615 , 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)





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