MEDICARE: MR. DAVID ROBERT GROSS PT

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	225100000X	Physical Therapist	5464	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60607	OTHER	WA	FIRST CHOICE
2	0201568	OTHER	WA	LABOR AND INDUSTRY
3	5623609	OTHER	WA	FIRST HEALTH
4	7775192	OTHER		AETNA
5	1136229	OTHER		CAQH
6	167753167755	OTHER	WA	PREMERA

General Provider Information

NPI Number	:	1225125511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID ROBERT GROSS PT

Provider Business Mailing Address
First Line	:	PO BOX 15627
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-0627
Country	:	US
Telephone Number	:	206-527-8628
Fax Number	:	206-527-8648

Provider Business Practice Location Address
First Line	:	2319 N 45TH ST
Second Line	:	SUITE 301
City	:	SEATTLE
State	:	WA
Zip	:	98103-6982
Country	:	US
Telephone Number	:	206-527-8628
Fax Number	:	206-527-8648

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	08/20/2010

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