Provider Demographics
NPI:1194705053
Name:GROSS, KIRSTEN M (MD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:GROSS
Suffix:
Gender:F
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9550 ROCKY RIVER RD STE 150
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:704-316-5281
Practice Address - Fax:704-316-5283
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38264207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN38264Medicaid
NC7937732Medicaid
NC7937732Medicaid
NC2164425CMedicare PIN