MEDICARE: FREDERICK WALTER GROSS MSW

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	1041C0700X	Clinical Social Worker		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	197088	OTHER	IL	COMPSYCH
2	0001671347	OTHER	IL	BLUE CROSS
3	16467890	OTHER	IL	UBH

General Provider Information

NPI Number	:	1568445286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK WALTER GROSS MSW

Provider Business Mailing Address
First Line	:	9251 S OAKLEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-6218
Country	:	US
Telephone Number	:	773-239-1221
Fax Number	:	773-239-7968

Provider Business Practice Location Address
First Line	:	10540 S WESTERN AVE
Second Line	:	SUITE 311
City	:	CHICAGO
State	:	IL
Zip	:	60643-2536
Country	:	US
Telephone Number	:	773-239-0404
Fax Number	:	773-239-7968

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/08/2007

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