Provider Demographics
NPI:1689867814
Name:GROSS, PAMELA
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 MISSIONARY DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 MISSIONARY DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3842
Practice Address - Country:US
Practice Address - Phone:404-329-1085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042589208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH78584Medicare UPIN