Healthcare Provider Details

I. General information

NPI: 1114303526
Provider Name (Legal Business Name): MADALIN GROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

1101 NE 3RD AVE
FORT LAUDERDALE FL
33304-1916
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-1323
  • Fax:
Mailing address:
  • Phone: 954-801-5005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number517399
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: