Healthcare Provider Details

I. General information

NPI: 1235614207
Provider Name (Legal Business Name): MICHAEL DAVID GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 CAPITAL BLVD
RALEIGH NC
27603-1118
US

IV. Provider business mailing address

905 CARPENTER TOWN LN
CARY NC
27519-9316
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-2180
  • Fax:
Mailing address:
  • Phone: 919-469-6598
  • Fax: 919-469-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number25589
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: