Provider Demographics
NPI:1285814491
Name:DARRYL S GROSS MD PC
Entity Type:Organization
Organization Name:DARRYL S GROSS MD PC
Other - Org Name:MEDICAL WEIGHT LOSS & FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-860-8860
Mailing Address - Street 1:2280 SALEM RD SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2003
Mailing Address - Country:US
Mailing Address - Phone:770-860-8860
Mailing Address - Fax:770-860-8890
Practice Address - Street 1:2280 SALEM RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2003
Practice Address - Country:US
Practice Address - Phone:770-860-8860
Practice Address - Fax:770-860-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6702OtherMEDICARE GROUP NUMBER ASS
GA01BDHSCMedicare PIN