MEDICARE: MR. MICHAEL DAVID GROSS CRNP

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	363L00000X	Nurse Practitioner	1-097473	AL

General Provider Information

NPI Number	:	1518256007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL DAVID GROSS CRNP

Provider Business Mailing Address
First Line	:	105 CHURCH ST
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-6242
Country	:	US
Telephone Number	:	256-442-5172
Fax Number	:	256-442-5507

Provider Business Practice Location Address
First Line	:	105 CHURCH ST
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-6242
Country	:	US
Telephone Number	:	256-442-5172
Fax Number	:	256-442-5507

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

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	11/06/2015

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