Provider Demographics
NPI:1063436491
Name:GROSSO, GINO (MD)
Entity type:Individual
Prefix:
First Name:GINO
Middle Name:
Last Name:GROSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 MARLTON PIKE E
Mailing Address - Street 2:SUITE G-38
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2150
Mailing Address - Country:US
Mailing Address - Phone:856-751-7280
Mailing Address - Fax:856-751-7209
Practice Address - Street 1:1930 MARLTON PIKE E
Practice Address - Street 2:SUITE G-38
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2150
Practice Address - Country:US
Practice Address - Phone:856-751-7280
Practice Address - Fax:856-751-7209
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA051760002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR 106088Medicare ID - Type Unspecified
C25977Medicare UPIN