Provider Demographics
NPI:1316028665
Name:DEL GROSSO, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:DEL GROSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 948
Mailing Address - Street 2:2112 CHERRY VALLEY RD.,
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-0948
Mailing Address - Country:US
Mailing Address - Phone:740-522-3774
Mailing Address - Fax:740-522-2221
Practice Address - Street 1:1320 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:740-348-4779
Practice Address - Fax:740-348-4740
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0790672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000195585OtherANTHEM BC/BS
310851206015OtherMEDICAL MUTUAL OF OHIO
000000195585OtherANTHEM BC/BS-FEDERAL
300124726OtherRAILROAD MEDICARE
OH2224524Medicaid
300124726OtherRAILROAD MEDICARE
310851206015OtherMEDICAL MUTUAL OF OHIO