Provider Demographics
NPI:1144393307
Name:GROSSMAN, GARY L (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17336 W 12 MILE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2113
Mailing Address - Country:US
Mailing Address - Phone:248-395-0080
Mailing Address - Fax:
Practice Address - Street 1:17336 W 12 MILE RD STE 106
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2113
Practice Address - Country:US
Practice Address - Phone:248-395-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M72130Medicare ID - Type Unspecified