Healthcare Provider Details

I. General information

NPI: 1538129879
Provider Name (Legal Business Name): THOMAS GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4318
US

IV. Provider business mailing address

6701 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4318
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-6200
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-727-6200
  • Fax: 505-727-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number88177
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number88-177
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: