Provider Demographics
NPI:1689661704
Name:GROSART, GARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:GROSART
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 1:200 MILL RD
Mailing Address - Street 2:STE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:208 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:508-996-1800
Practice Address - Fax:508-992-7906
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40157207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110036879AMedicaid
MA002562201Medicare PIN
A59686Medicare UPIN