Provider Demographics
NPI:1083851737
Name:GROSS, ERICA RACHEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:RACHEL
Last Name:GROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-2034
Mailing Address - Fax:631-444-8947
Practice Address - Street 1:100 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-4874
Practice Address - Country:US
Practice Address - Phone:631-444-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI609422086S0120X
NJ25MA112484002086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400140609Medicare PIN