Healthcare Provider Details

I. General information

NPI: 1134218993
Provider Name (Legal Business Name): BETH R GROSS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 NORTHERN BLVD STE 106
MANHASSET NY
11030-3033
US

IV. Provider business mailing address

900 MERCHANTS CONCOURSE STE 216
WESTBURY NY
11590-5114
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-2500
  • Fax: 516-365-4980
Mailing address:
  • Phone: 516-226-8373
  • Fax: 844-632-8265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number164265
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: