Healthcare Provider Details

I. General information

NPI: 1942798608
Provider Name (Legal Business Name): ANDREW JONATHAN GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2018
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9485 MENTOR AVE STE 3
MENTOR OH
44060-8711
US

IV. Provider business mailing address

11919 CLARIDON TROY RD
CHARDON OH
44024-8441
US

V. Phone/Fax

Practice location:
  • Phone: 440-205-5788
  • Fax: 440-205-5781
Mailing address:
  • Phone: 330-805-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.246406
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35.147954
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: