Healthcare Provider Details

I. General information

NPI: 1013916717
Provider Name (Legal Business Name): WAYNE D GROSS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 MARION AVE NW SUITE 200
MASSILLON OH
44646-3639
US

IV. Provider business mailing address

323 MARION AVE NW SUITE 200
MASSILLON OH
44646-3639
US

V. Phone/Fax

Practice location:
  • Phone: 330-837-1111
  • Fax: 330-837-1769
Mailing address:
  • Phone: 330-837-1111
  • Fax: 330-837-1769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34005735
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: