Provider Demographics
NPI:1225011786
Name:GROSSMAN, MICHAEL R (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E CITY AVE
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1501
Mailing Address - Country:US
Mailing Address - Phone:610-645-6314
Mailing Address - Fax:610-645-9923
Practice Address - Street 1:333 E CITY AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1501
Practice Address - Country:US
Practice Address - Phone:610-645-6314
Practice Address - Fax:610-645-9923
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003470R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013601290Medicaid
PAU18202Medicare UPIN
PA674739PXYMedicare ID - Type Unspecified