Provider Demographics
NPI:1285635805
Name:GROSS, SHELDON WARREN (MD)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:WARREN
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:WARREN
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:191 PRESIDENTIAL BLVD
Mailing Address - Street 2:UNIT 217
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1217
Mailing Address - Country:US
Mailing Address - Phone:856-231-4774
Mailing Address - Fax:856-231-9699
Practice Address - Street 1:191 PRESIDENTIAL BLVD
Practice Address - Street 2:UNIT 217
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1217
Practice Address - Country:US
Practice Address - Phone:856-661-5473
Practice Address - Fax:856-661-5470
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA058277002085R0202X
PAMD008874E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4603001Medicaid
NJ774329Medicare ID - Type Unspecified
PAC31917Medicare UPIN