MEDICARE: DR. MICHAEL LESLIE GROSS M.D.

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	207N00000X	Dermatology Physician	0101052313	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	070008396	OTHER	VA	RR MEDICARE

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	77060	OTHER	VA	OPTIMA
3	075428	OTHER	VA	ANTHEM BC/BS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932105285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LESLIE GROSS M.D.

Provider Business Mailing Address
First Line	:	828 HEALTHY WAY
Second Line	:	SUITE 300
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-7958
Country	:	US
Telephone Number	:	757-965-6165
Fax Number	:	757-965-6296

Provider Business Practice Location Address
First Line	:	828 HEALTHY WAY
Second Line	:	SUITE 300
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-7958
Country	:	US
Telephone Number	:	757-965-6165
Fax Number	:	757-965-6296

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	05/23/2012

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Directions to “ DR. MICHAEL LESLIE GROSS M.D.” Practice Location

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