Provider Demographics
NPI:1255483525
Name:GROSSMAN AND GROSSMAN MDS A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GROSSMAN AND GROSSMAN MDS A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-498-0240
Mailing Address - Street 1:558 N VENTU PARK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2718
Mailing Address - Country:US
Mailing Address - Phone:805-498-0240
Mailing Address - Fax:
Practice Address - Street 1:558 N VENTU PARK RD
Practice Address - Street 2:SUITE A
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-2718
Practice Address - Country:US
Practice Address - Phone:805-498-0240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11839Medicare PIN