Healthcare Provider Details

I. General information

NPI: 1467562470
Provider Name (Legal Business Name): ANDREW LANE GROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 3RD ST # 81416
DELTA CO
81416-2815
US

IV. Provider business mailing address

PO BOX 10100
DELTA CO
81416-0008
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7681
  • Fax:
Mailing address:
  • Phone: 970-874-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-39723
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number44054
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: