Provider Demographics
NPI:1194281113
Name:GROSS, ELLIOT R
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:R
Last Name:GROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2911
Mailing Address - Country:US
Mailing Address - Phone:718-208-8941
Mailing Address - Fax:
Practice Address - Street 1:28 MARSHALL DR
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2911
Practice Address - Country:US
Practice Address - Phone:718-208-8941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program