MEDICARE: JEFFREY GROSS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2085R0001X	Radiation Oncology Physician	125066687	IL

General Provider Information

NPI Number	:	1730578527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY GROSS

Provider Business Mailing Address
First Line	:	NMH/ARKES FAMILY PAVILION SUITE 1820
Second Line	:	676 N SAINT CLAIR
City	:	CHICAGO
State	:	IL
Zip	:	60611
Country	:	US
Telephone Number	:	312-926-2520
Fax Number	:

Provider Business Practice Location Address
First Line	:	6525 N MOZART ST
Second Line	:	APT 3
City	:	CHICAGO
State	:	IL
Zip	:	60645-4377
Country	:	US
Telephone Number	:	248-761-6628
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2015
Last Update Date	:	03/08/2016

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