=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346229127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NED JAY GROSS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2006
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 FAIRY STREET EXT SUITE D
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-666-8439
-----------------------------------------------------
Fax | 276-666-8440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 FAIRY STREET EXT SUITE D
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-666-8439
-----------------------------------------------------
Fax | 276-666-8440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 200000811
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 0101228761
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------