Basic Information
| Provider Information | |||||||||
| NPI: | 1497715585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | MARTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | 400-FSC/PCS | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301046830 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4288161 | 05 | MI | MEDICAID | 300F362480 | 01 | MI | BCBSM | OTHER |