Provider Demographics
NPI:1619030939
Name:GROSSBERG, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:GROSSBERG
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 1:7096 SOUTHWOODS LANE
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-5105
Mailing Address - Country:US
Mailing Address - Phone:440-914-7840
Mailing Address - Fax:440-914-7855
Practice Address - Street 1:7096 SOUTHWOODS LANE
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-5105
Practice Address - Country:US
Practice Address - Phone:440-914-7840
Practice Address - Fax:440-914-7855
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-6687-G2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2143273Medicaid
OH2143273Medicaid
OHH002150Medicare PIN
OH4039562Medicare PIN