Provider Demographics
NPI:1467480855
Name:GROSSMAN, JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:GROSSMAN
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:PO BOX 2425
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2425
Mailing Address - Country:US
Mailing Address - Phone:828-277-1300
Mailing Address - Fax:828-277-2499
Practice Address - Street 1:1521 E TANGERINE RD
Practice Address - Street 2:SUITE 311
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6225
Practice Address - Country:US
Practice Address - Phone:520-797-3111
Practice Address - Fax:520-326-2575
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20520207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123662Medicaid
AZ123662Medicaid
AZB80802Medicare UPIN
AZP00333891Medicare PIN