Provider Demographics
NPI:1689719221
Name:GROSS, MARLENE ADRIENE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:ADRIENE
Last Name:GROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2813
Mailing Address - Country:US
Mailing Address - Phone:215-477-2017
Mailing Address - Fax:
Practice Address - Street 1:6101 LANDSDOWNE AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151
Practice Address - Country:US
Practice Address - Phone:215-477-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine