Provider Demographics
NPI:1477618270
Name:GROSSMAN, LAWRENCE B (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:B
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 1:2000 GRANT AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4378
Mailing Address - Country:US
Mailing Address - Phone:215-333-1776
Mailing Address - Fax:215-333-0653
Practice Address - Street 1:2000 GRANT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:215-333-1776
Practice Address - Fax:215-333-0653
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050925L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010101650037Medicaid
G25306Medicare UPIN
PA0010101650037Medicaid