Provider Demographics
NPI:1760488647
Name:GROSE, GREGORY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:GROSE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1414 N TAYLOR DR
Mailing Address - Street 2:STE 210
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3090
Mailing Address - Country:US
Mailing Address - Phone:920-457-4858
Mailing Address - Fax:920-457-3650
Practice Address - Street 1:1414 N TAYLOR DR
Practice Address - Street 2:STE 210
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3090
Practice Address - Country:US
Practice Address - Phone:920-457-4858
Practice Address - Fax:920-457-3650
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2011-07-25
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Provider Licenses
StateLicense IDTaxonomies
WI32294208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31708200Medicaid
WIF26291Medicare UPIN
WI31708200Medicaid