Provider Demographics
NPI:1033381280
Name:BRUCE M GROSSMAN M D P A
Entity Type:Organization
Organization Name:BRUCE M GROSSMAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-691-9660
Mailing Address - Street 1:3370 BURNS RD
Mailing Address - Street 2:105
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4327
Mailing Address - Country:US
Mailing Address - Phone:561-691-9660
Mailing Address - Fax:561-691-9633
Practice Address - Street 1:3370 BURNS RD
Practice Address - Street 2:105
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4327
Practice Address - Country:US
Practice Address - Phone:561-691-9660
Practice Address - Fax:561-691-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0053017207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049666900Medicaid
FL07622Medicare PIN
FLB63511Medicare UPIN