Provider Demographics
NPI:1336310226
Name:PETER G GROSS MD PHD PC
Entity Type:Organization
Organization Name:PETER G GROSS MD PHD PC
Other - Org Name:EYE STAR VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:610-636-1874
Mailing Address - Street 1:958 COUNTY LINE RD
Mailing Address - Street 2:CONESTOGA MEDICAL BUILDING SUITE 106
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2585
Mailing Address - Country:US
Mailing Address - Phone:610-525-8282
Mailing Address - Fax:610-525-7766
Practice Address - Street 1:958 COUNTY LINE RD
Practice Address - Street 2:CONESTOGA MEDICAL BUILDING SUITE 106
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2585
Practice Address - Country:US
Practice Address - Phone:610-525-8282
Practice Address - Fax:610-525-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029947E207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6225420001Medicare NSC