Provider Demographics
NPI:1376561720
Name:GROSSETT, ROBERT T (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:GROSSETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1421
Mailing Address - Country:US
Mailing Address - Phone:651-292-2009
Mailing Address - Fax:651-292-2144
Practice Address - Street 1:166 4TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1421
Practice Address - Country:US
Practice Address - Phone:651-292-2009
Practice Address - Fax:651-292-2144
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360909132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360909133Medicaid
ILL88080Medicare PIN
IL0360909133Medicaid