Provider Demographics
NPI:1104847953
Name:GROSSMAN, KENNETH PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:801 ALBANY ST FL G
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:FASTER PATHS
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-4580
Practice Address - Fax:617-414-4572
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2022-10-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA48029207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA66313Medicare UPIN