Provider Demographics
NPI:1700842762
Name:GROSSMAN, CHERYL RENEE (PAC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:RENEE
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:410-494-1324
Mailing Address - Fax:410-494-1361
Practice Address - Street 1:515 FAIRMOUNT AVE STE 400
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-8518
Practice Address - Country:US
Practice Address - Phone:410-494-1313
Practice Address - Fax:410-584-2250
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD798621100Medicaid
459789ZR0ZMedicare PIN
MDD72046Medicare UPIN
MD798621100Medicaid