Provider Demographics
NPI:1417139155
Name:MELVIN K. GROSS
Entity Type:Organization
Organization Name:MELVIN K. GROSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:AU D
Authorized Official - Phone:513-829-7111
Mailing Address - Street 1:1251 NILLES RD
Mailing Address - Street 2:SUITE #7
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7206
Mailing Address - Country:US
Mailing Address - Phone:513-829-7111
Mailing Address - Fax:
Practice Address - Street 1:1251 NILLES RD
Practice Address - Street 2:SUITE #7
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7206
Practice Address - Country:US
Practice Address - Phone:513-829-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA0108231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0665632Medicaid
OH0665632Medicaid