Healthcare Provider Details

I. General information

NPI: 1245895663
Provider Name (Legal Business Name): ANDREW B GROSE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 W 280 N
PROVIDENCE UT
84332-9118
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-0330
  • Fax: 435-755-0922
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12897926-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: