Provider Demographics
NPI:1598946022
Name:GROSS, ERIC T (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:T
Last Name:GROSS
Suffix:
Gender:M
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 1:6674 TIPPECANOE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9149
Mailing Address - Country:US
Mailing Address - Phone:330-533-0919
Mailing Address - Fax:330-533-1732
Practice Address - Street 1:6674 TIPPECANOE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9149
Practice Address - Country:US
Practice Address - Phone:330-533-0919
Practice Address - Fax:330-533-1732
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35 071295208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000336206OtherANTHEM BC/BS
OH2118578Medicaid
OH2118578Medicaid
OH0873642Medicare PIN