Healthcare Provider Details

I. General information

NPI: 1942520499
Provider Name (Legal Business Name): TERESA ROSE RECKER GROSS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. TERESA ROSE RECKER

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 01/25/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 W CENTRAL AVE SUITE 103
DELAWARE OH
43015-1493
US

IV. Provider business mailing address

551 W CENTRAL AVE SUITE 103
DELAWARE OH
43015-1493
US

V. Phone/Fax

Practice location:
  • Phone: 740-615-0300
  • Fax: 740-615-0301
Mailing address:
  • Phone: 740-615-0300
  • Fax: 740-615-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34011085
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: