Provider Demographics
NPI:1669484481
Name:JEREMY IAN GROSSER MD INC.
Entity Type:Organization
Organization Name:JEREMY IAN GROSSER MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:GROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-929-2259
Mailing Address - Street 1:109 DAPPLEGRAY RD
Mailing Address - Street 2:
Mailing Address - City:BELL CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1050
Mailing Address - Country:US
Mailing Address - Phone:818-929-2259
Mailing Address - Fax:818-700-5690
Practice Address - Street 1:7355 TOPANGA CANYON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1244
Practice Address - Country:US
Practice Address - Phone:818-885-8500
Practice Address - Fax:818-700-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2022-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19299Medicare PIN
CAH91068Medicare UPIN