Provider Demographics
NPI:1609053990
Name:DR. KEVIN J. GROSS OPTOMETRY P.A.
Entity Type:Organization
Organization Name:DR. KEVIN J. GROSS OPTOMETRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-574-3491
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:SECTION
Mailing Address - State:AL
Mailing Address - Zip Code:35771-0290
Mailing Address - Country:US
Mailing Address - Phone:256-574-3491
Mailing Address - Fax:256-259-5113
Practice Address - Street 1:24020 JOHN T REID PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2855
Practice Address - Country:US
Practice Address - Phone:256-574-3491
Practice Address - Fax:256-259-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS554-TA-220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059775Medicaid
AL51059775OtherBCBS
ALT68921Medicare UPIN