Provider Demographics
NPI:1215558473
Name:GROSS, TERAGA
Entity Type:Individual
Prefix:
First Name:TERAGA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 IVANHOE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-4322
Mailing Address - Country:US
Mailing Address - Phone:443-627-3083
Mailing Address - Fax:
Practice Address - Street 1:5201 IVANHOE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-4322
Practice Address - Country:US
Practice Address - Phone:443-627-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management