Provider Demographics
NPI:1588660021
Name:GROSSMAN, JAY S (DO)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:S
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 OLD YORK RD
Mailing Address - Street 2:NORTH COURT
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2882
Mailing Address - Country:US
Mailing Address - Phone:215-885-4733
Mailing Address - Fax:
Practice Address - Street 1:678 OLD YORK RD
Practice Address - Street 2:NORTH COURT
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2882
Practice Address - Country:US
Practice Address - Phone:215-885-4733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002853L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA136496Medicare PIN