Provider Demographics
NPI:1467409862
Name:GROSS, SAMUEL NORMAN (MSRDLD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:NORMAN
Last Name:GROSS
Suffix:
Gender:M
Credentials:MSRDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 HOOVER DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-1690
Mailing Address - Country:US
Mailing Address - Phone:620-617-8247
Mailing Address - Fax:888-617-8247
Practice Address - Street 1:415 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:ELLINWOOD
Practice Address - State:KS
Practice Address - Zip Code:67526-1419
Practice Address - Country:US
Practice Address - Phone:620-564-2922
Practice Address - Fax:620-564-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1236133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS120533OtherBLUE CROSS NUTRITIONIST
KS200366270BMedicaid