Healthcare Provider Details

I. General information

NPI: 1043640840
Provider Name (Legal Business Name): ERNEST JAY GROSS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 LOCUST ST
PROVIDENCE KY
42450-1514
US

IV. Provider business mailing address

206 LOCUST ST
PROVIDENCE KY
42450-1514
US

V. Phone/Fax

Practice location:
  • Phone: 205-919-0863
  • Fax:
Mailing address:
  • Phone: 205-919-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2329494
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP11000776
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number52674
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number27565
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD166143
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: