Provider Demographics
NPI:1558556753
Name:GROMACK, GARY RICHARD (MED CCC A)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:RICHARD
Last Name:GROMACK
Suffix:
Gender:M
Credentials:MED CCC A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 HAMBURG TPKE STE 104
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2049
Mailing Address - Country:US
Mailing Address - Phone:862-257-1370
Mailing Address - Fax:
Practice Address - Street 1:601 HAMBURG TPKE STE 104
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470
Practice Address - Country:US
Practice Address - Phone:862-257-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00049600237600000X
NY0007561231H00000X
NJ41YA00007600237600000X
NJ41YA000076231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ213084Medicare PIN
NYM74621Medicare PIN