Provider Demographics
NPI:1306903109
Name:CHARLES B. GOSS, D.O., P.C.
Entity type:Organization
Organization Name:CHARLES B. GOSS, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-471-5700
Mailing Address - Street 1:28100 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5967
Mailing Address - Country:US
Mailing Address - Phone:248-471-5700
Mailing Address - Fax:248-851-5515
Practice Address - Street 1:28100 GRAND RIVER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5967
Practice Address - Country:US
Practice Address - Phone:248-471-5700
Practice Address - Fax:248-851-5515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1091313 11 00Medicaid
MI260F338480OtherBLUE CROSS & BLUE SHIELD
MIE31656Medicare UPIN
MI1091313 11 00Medicaid