Healthcare Provider Details

I. General information

NPI: 1730578527
Provider Name (Legal Business Name): JEFFREY GROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 N MOZART ST APT 3
CHICAGO IL
60645-4377
US

IV. Provider business mailing address

NMH/ARKES FAMILY PAVILION SUITE 1820 676 N SAINT CLAIR
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 248-761-6628
  • Fax:
Mailing address:
  • Phone: 312-926-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number125066687
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: