Healthcare Provider Details

I. General information

NPI: 1548228588
Provider Name (Legal Business Name): RUSSELL J GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 HIGHWAY 51 S SUITE 203
COVINGTON TN
38019-3635
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD SUITE 103
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 901-475-5422
  • Fax: 901-475-5595
Mailing address:
  • Phone: 901-227-4068
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA31869
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number40003
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number31869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: