Provider Demographics
NPI:1598871097
Name:GROSS, PAUL KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:KENNETH
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 1:401 N 17TH STREET
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5014
Mailing Address - Country:US
Mailing Address - Phone:610-820-3900
Mailing Address - Fax:610-820-3835
Practice Address - Street 1:401 N 17TH STREET
Practice Address - Street 2:SUITE 304
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5014
Practice Address - Country:US
Practice Address - Phone:610-820-3900
Practice Address - Fax:610-820-3835
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014403E2084F0202X, 2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005529530001Medicaid
PA01197501OtherCAPITAL BLUE CROSS
004780000OtherMAGELLAN
P711319OtherOXFORD
PA260045197OtherRAILROAD MEDICARE
PA163384OtherHIGHMARK BLUE SHIELD
PA260045197OtherRAILROAD MEDICARE
PA0005529530001Medicaid