Provider Demographics
NPI:1215902648
Name:GROSS, LYNDON BERNARD (MD, PHD)
Entity type:Individual
Prefix:
First Name:LYNDON
Middle Name:BERNARD
Last Name:GROSS
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Gender:M
Credentials:MD, PHD
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Other - Credentials:
Mailing Address - Street 1:11330 OLIVE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-336-2566
Mailing Address - Fax:314-948-9011
Practice Address - Street 1:11330 OLIVE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-336-2566
Practice Address - Fax:314-948-9011
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2024-06-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO119343204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG82897Medicare UPIN