Provider Demographics
NPI:1245239102
Name:GROSSMAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-0315
Mailing Address - Country:US
Mailing Address - Phone:334-756-9604
Mailing Address - Fax:334-756-9606
Practice Address - Street 1:4505 20TH AVE
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3542
Practice Address - Country:US
Practice Address - Phone:334-756-9604
Practice Address - Fax:334-756-9606
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007925207P00000X
ALMD.7925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000181145EMedicaid
AL009929055Medicaid
AL51516975OtherBC/BS ALABAMA
AL051554816Medicare ID - Type Unspecified
AL009929055Medicaid