Provider Demographics
NPI:1205893229
Name:GROSS, STEPHEN B (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 WELLS ST STE 204
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2927
Practice Address - Country:US
Practice Address - Phone:401-637-7929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08611207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010008611RI01OtherBLUE CROSS CONNECTICUT
RI9021202Medicaid
RIF78797Medicare UPIN
6160710001Medicare NSC
RI209082059Medicare PIN