Provider Demographics
NPI:1497739072
Name:GROSE, RICHARD MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARC
Last Name:GROSE
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 1:314 W 100TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5337
Mailing Address - Country:US
Mailing Address - Phone:914-906-6537
Mailing Address - Fax:
Practice Address - Street 1:314 W 100TH ST
Practice Address - Street 2:APT 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5337
Practice Address - Country:US
Practice Address - Phone:914-906-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD124082207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
B77659Medicare UPIN
NY15A891Medicare PIN
NY124082OtherHIP
B77659Medicare UPIN
NY15A891Medicare PIN
NY124082NYOtherLOCAL 1199
NY2100546OtherGHI PPO CBP
NY000000031941OtherGHI HMO
NY10621OtherCONTRACT MANAGEMENT ORG
NY0H4259OtherHEALTHNET
NY338641OtherUNITED HEALTHCARE
NYWS411OtherOXFORD
NY00417827Medicaid