Provider Demographics
NPI:1235118217
Name:GROSS, PETER LLOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LLOYD
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-2374
Mailing Address - Fax:617-726-4495
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WAC 612
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-2374
Practice Address - Fax:617-726-4495
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2031116Medicaid
MAM08984OtherBCBS MA
MA035884OtherTUFTS HEALTH PLAN
MAM08984Medicare ID - Type Unspecified
MA035884OtherTUFTS HEALTH PLAN