Provider Demographics
NPI:1255305686
Name:GROSS, RUSSELL A (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:732-615-3900
Mailing Address - Fax:732-615-0865
Practice Address - Street 1:1270 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2014
Practice Address - Country:US
Practice Address - Phone:732-615-3900
Practice Address - Fax:732-615-0865
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03612600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1686402Medicaid
NJ200993DE4OtherMEDICARE
NJC59931Medicare UPIN