Healthcare Provider Details

I. General information

NPI: 1811952294
Provider Name (Legal Business Name): BARRY J GROSS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9838 DIXIE HWY
FAIR HAVEN MI
48023-2813
US

IV. Provider business mailing address

9838 DIXIE HWY
FAIR HAVEN MI
48023-2813
US

V. Phone/Fax

Practice location:
  • Phone: 586-725-9611
  • Fax: 586-725-2630
Mailing address:
  • Phone: 586-725-9611
  • Fax: 586-725-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number5101007067
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101007067
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: