Provider Demographics
NPI:1194783852
Name:GROSS, ERIC (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GROSS
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 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:101 JORDAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8343
Practice Address - Country:US
Practice Address - Phone:518-274-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCH8587OtherRAILROAD MEDICARE
NYAA0890OtherMEDICARE
NY00314374Medicaid
NYCH8587OtherRAILROAD MEDICARE
D78412Medicare UPIN