Healthcare Provider Details

I. General information

NPI: 1023481116
Provider Name (Legal Business Name): MRS. ROSE GROSSIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S NEW BALLAS RD SUITE 350
SAINT LOUIS MO
63141-8704
US

IV. Provider business mailing address

763 S NEW BALLAS RD SUITE 350
SAINT LOUIS MO
63141-8704
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-5144
  • Fax: 314-432-2400
Mailing address:
  • Phone: 314-432-5144
  • Fax: 314-432-2400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2015039575
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015039575
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: