Basic Information
| Provider Information | |||||||||
| NPI: | 1336143247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LANCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 W PARK AVE | ||||||||
| Address2: | STE 213 | ||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077128526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326952555 | ||||||||
| FaxNumber: | 7326952552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | MA048056 | NJ | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | 25MA04805600 | NJ | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 029133ZKRP | 01 | NJ | MEDICARE PTAN | OTHER | 3408400 | 05 | NJ | MEDICAID | 029133ZVF5 | 01 | NJ | MEDICARE PTAN | OTHER |