Provider Demographics
NPI:1811952294
Name:GROSS, BARRY J (DO)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:J
Last Name:GROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9838 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2813
Mailing Address - Country:US
Mailing Address - Phone:586-725-9611
Mailing Address - Fax:586-725-2630
Practice Address - Street 1:9838 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FAIR HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48023-2813
Practice Address - Country:US
Practice Address - Phone:586-725-9611
Practice Address - Fax:586-725-2630
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007067207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1097101Medicaid
MI1097101Medicaid
MI5740064Medicare ID - Type Unspecified