Healthcare Provider Details

I. General information

NPI: 1003854878
Provider Name (Legal Business Name): CRAIG M. GROSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 S HIGHWAY 99
FILLMORE UT
84631-5134
US

IV. Provider business mailing address

1055 NORTH 500 WEST ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 435-864-3333
  • Fax: 435-864-2790
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3243941205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: