Basic Information
| Provider Information | |||||||||
| NPI: | 1316028665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEL GROSSO | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 948 | ||||||||
| Address2: | 2112 CHERRY VALLEY RD., | ||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430580948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405223774 | ||||||||
| FaxNumber: | 7405222221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403484779 | ||||||||
| FaxNumber: | 7403484740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35-079067 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000195585 | 01 | ANTHEM BC/BS | OTHER | 310851206015 | 01 | MEDICAL MUTUAL OF OHIO | OTHER | 000000195585 | 01 | ANTHEM BC/BS-FEDERAL | OTHER | 300124726 | 01 | RAILROAD MEDICARE | OTHER | 2224524 | 05 | OH | MEDICAID |