Provider Demographics
NPI:1467568618
Name:GROSS, CHARLES A (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:GROSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 RIVER OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5826
Mailing Address - Country:US
Mailing Address - Phone:708-862-0111
Mailing Address - Fax:708-862-0175
Practice Address - Street 1:500 RIVER OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5826
Practice Address - Country:US
Practice Address - Phone:708-862-0111
Practice Address - Fax:708-862-0175
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634338OtherBCBS
IL532780Medicare ID - Type Unspecified