Theodore Gross

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

M-15894 Issued in ID

Practice address

1100 NW 12TH St
Fruitland, ID 83619-5040

Phone

(208) 452-6556

NPI assigned

Apr 10, 2017

Last updated

Aug 5, 2025By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Snake River Pediatrics, PC

  • Rural Health Clinic/Center
  • Fruitland, ID
  • NPI 1720489396
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491782400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1754352000000",
    "number": "1922531508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 NW 12TH ST",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836195040",
            "telephone_number": "208-452-6556"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 NW 12TH ST",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836195040",
            "telephone_number": "208-452-6556"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GROSS",
        "first_name": "THEODORE",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-04-10",
        "last_updated": "2025-08-05",
        "certification_date": "2025-08-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "ID",
            "license": "M-15894",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alia Bonnie Fulleton, LPC
• Billy J Galligar, MD
• Colleen E Gardner, LCPC, NCC
• Golden Mountain Wellness LLC
• Good Life Physical Therapy PLLC
• Guardian Home Care, Inc (Enhabit Hospice of Idaho)
• Curtis J Guiles, DDS
• Sean P Hackett, PA-C
• Craig L Hamann, D.P.T.
• Nicholas Cole Hartley, DPT

• Pediatrics Physician in Fruitland, ID
• Providers in Fruitland, ID by specialty
• Pediatrics Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.