Provider Demographics
NPI:1073689097
Name:GROSSMAN, FERN MARLA (DC)
Entity Type:Individual
Prefix:
First Name:FERN
Middle Name:MARLA
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 GRANT AVE
Mailing Address - Street 2:GRANT PLAZA II
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3167
Mailing Address - Country:US
Mailing Address - Phone:215-934-5401
Mailing Address - Fax:215-934-5452
Practice Address - Street 1:1619 GRANT AVE
Practice Address - Street 2:GRANT PLAZA II
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3167
Practice Address - Country:US
Practice Address - Phone:215-934-5401
Practice Address - Fax:215-934-5452
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006309L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2053318000OtherIBX
PA058551Medicare ID - Type Unspecified