Provider Demographics
NPI:1467492496
Name:GROSS, LEE S (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:S
Last Name:GROSS
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 1:2975 BOBCAT VILLAGE CENTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-4600
Mailing Address - Country:US
Mailing Address - Phone:941-423-9936
Mailing Address - Fax:941-426-9794
Practice Address - Street 1:2975 BOBCAT VILLAGE CENTER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-4600
Practice Address - Country:US
Practice Address - Phone:941-423-9936
Practice Address - Fax:941-426-9794
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H54129Medicare UPIN
15815YMedicare ID - Type Unspecified