Provider Demographics
NPI:1578564605
Name:GROSS, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:GROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 N MCCORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1702
Mailing Address - Country:US
Mailing Address - Phone:419-843-8160
Mailing Address - Fax:419-841-7038
Practice Address - Street 1:3020 N MCCORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-1702
Practice Address - Country:US
Practice Address - Phone:419-843-8160
Practice Address - Fax:419-841-7038
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04-03000OtherUHC
OH0638005OtherAETNA
OH29556773-003OtherMMO
OH000000141247OtherANTHEM
OH0163433Medicaid
OH11062OtherHPM
OH01991OtherPARAMOUNT
OHG04040Medicare UPIN
OH0163433Medicaid