Provider Demographics
NPI:1083487698
Name:GROSS, MICHAEL BENJAMIN (RN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:GROSS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 W 163RD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-5703
Mailing Address - Country:US
Mailing Address - Phone:516-439-8299
Mailing Address - Fax:
Practice Address - Street 1:611 W 171ST ST APT 4B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1948
Practice Address - Country:US
Practice Address - Phone:516-439-8299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013311101YM0800X
NY90865401163W00000X
NY407139363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse