Provider Demographics
NPI:1548228588
Name:GROSS, RUSSELL J (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1995 HIGHWAY 51 S
Practice Address - Street 2:SUITE 203
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3635
Practice Address - Country:US
Practice Address - Phone:901-475-5422
Practice Address - Fax:901-475-5595
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA31869208600000X
TN400032086S0129X
CA31869208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4167965OtherBCBS TN
0989653OtherCIGNA
TN42359OtherMEDICAID TLC
TN1507224Medicaid
TN33352371Medicare PIN
0989653OtherCIGNA
TN4167965OtherBCBS TN