Healthcare Provider Details

I. General information

NPI: 1396048005
Provider Name (Legal Business Name): S WARREN GROSS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 WHITE HORSE PIKE
ATCO NJ
08004-2230
US

IV. Provider business mailing address

131 GAITHER DR STE D SUITE D
MOUNT LAUREL NJ
08054-1709
US

V. Phone/Fax

Practice location:
  • Phone: 856-809-0900
  • Fax: 888-268-7603
Mailing address:
  • Phone: 856-234-1241
  • Fax: 856-234-5608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA05827700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number25MA05827700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. S WARREN GROSS
Title or Position: OWNER
Credential: M.D.
Phone: 610-331-4360