MEDICARE: JEFFREY NICHOLS GROSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	61809	KY

General Provider Information

NPI Number	:	1134681166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY NICHOLS GROSS

Provider Business Mailing Address
First Line	:	4111 OECHSLI AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-5022
Country	:	US
Telephone Number	:	502-576-6918
Fax Number	:

Provider Business Practice Location Address
First Line	:	4111 OECHSLI AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-5022
Country	:	US
Telephone Number	:	502-576-6918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2019
Last Update Date	:	06/22/2026

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