MEDICARE: DR. KEVIN J. GROSS OPTOMETRY P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S554-TA-220	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	51059775	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1609053990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. KEVIN J. GROSS OPTOMETRY P.A.

Provider Business Mailing Address
First Line	:	PO BOX 290
Second Line	:
City	:	SECTION
State	:	AL
Zip	:	35771-0290
Country	:	US
Telephone Number	:	256-574-3491
Fax Number	:	256-259-5113

Provider Business Practice Location Address
First Line	:	24020 JOHN T REID PKWY
Second Line	:
City	:	SCOTTSBORO
State	:	AL
Zip	:	35768-2855
Country	:	US
Telephone Number	:	256-574-3491
Fax Number	:	256-259-5113

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEVIN J. GROSS
Credential	:	OD
Telephone Number	:	256-574-3491

Provider Enumeration Date	:	01/29/2008
Last Update Date	:	05/17/2021

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