Provider Demographics
NPI:1609987890
Name:GROSS, MICHAEL DAVID (MD, JD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:GROSS
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Gender:M
Credentials:MD, JD
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Mailing Address - Street 1:2101 W BELMONT AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6413
Mailing Address - Country:US
Mailing Address - Phone:708-638-2417
Mailing Address - Fax:773-472-2473
Practice Address - Street 1:2101 W BELMONT AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6413
Practice Address - Country:US
Practice Address - Phone:708-638-2417
Practice Address - Fax:773-472-2473
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036 078620207P00000X, 207Q00000X, 2083X0100X, 209800000X
IL0360786202081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK31293Medicare PIN
ILC34238Medicare UPIN