Provider Demographics
NPI:1033135991
Name:GROSSBERG, GEORGE T (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:GROSSBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 S GRAND BLVD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1027
Mailing Address - Country:US
Mailing Address - Phone:314-977-4825
Mailing Address - Fax:
Practice Address - Street 1:1438 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1027
Practice Address - Country:US
Practice Address - Phone:314-977-4829
Practice Address - Fax:314-268-5494
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR69572084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry