Provider Demographics
NPI:1992749535
Name:GROSS, SHANIN R (DO)
Entity type:Individual
Prefix:
First Name:SHANIN
Middle Name:R
Last Name:GROSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5507
Mailing Address - Country:US
Mailing Address - Phone:215-563-0658
Mailing Address - Fax:
Practice Address - Street 1:809 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5507
Practice Address - Country:US
Practice Address - Phone:215-563-0658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011030L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H55617Medicare UPIN
PA054624Medicare ID - Type Unspecified