Provider Demographics
NPI:1427012533
Name:GROSSMAN, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:180 WHITE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1166
Mailing Address - Country:US
Mailing Address - Phone:732-842-5222
Mailing Address - Fax:732-741-6285
Practice Address - Street 1:180 WHITE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1166
Practice Address - Country:US
Practice Address - Phone:732-842-5222
Practice Address - Fax:732-741-6285
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04207000207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ022622Medicare PIN
NJC08403Medicare UPIN