Provider Demographics
NPI:1083768055
Name:GROSSMAN, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:GROSSMAN
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 1:1321 NW 14TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1673
Mailing Address - Country:US
Mailing Address - Phone:305-325-4888
Mailing Address - Fax:305-547-1508
Practice Address - Street 1:1321 NW 14TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1673
Practice Address - Country:US
Practice Address - Phone:305-325-4888
Practice Address - Fax:305-547-1508
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32744207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037155600Medicaid
FL1083768055OtherNPI
FL95004Medicare PIN