Provider Demographics
NPI:1518611821
Name:GROSMAN, NICHOLAS WILLIAM
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:GROSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 W FRIENDLY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4210
Mailing Address - Country:US
Mailing Address - Phone:336-292-9953
Mailing Address - Fax:
Practice Address - Street 1:5410 W FRIENDLY AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4210
Practice Address - Country:US
Practice Address - Phone:336-292-9953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5459OtherMEDICAL LICENSE