Basic Information
| Provider Information | |||||||||
| NPI: | 1548228588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012274068 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1995 HIGHWAY 51 S | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | COVINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380193635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014755422 | ||||||||
| FaxNumber: | 9014755595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A31869 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 40003 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 31869 | CA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4167965 | 01 | TN | BCBS TN | OTHER | 0989653 | 01 | CIGNA | OTHER | 42359 | 01 | TN | MEDICAID TLC | OTHER | 1507224 | 05 | TN | MEDICAID |