Basic Information
| Provider Information | |||||||||
| NPI: | 1396733630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOSS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1376 | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
| FaxNumber: | 9199897297 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N BRIGHT LEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199348171 | ||||||||
| FaxNumber: | 9199897297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101010315 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5101010315 | 01 | CONTROLLED SUBSTANCE | OTHER | BG1982366 | 01 | DEA | OTHER | 4553986 | 05 | MI | MEDICAID |