Provider Demographics
NPI:1710929708
Name:GROSSMAN, MICHAEL ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
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 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2507
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:965 SHAMROCK LN
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1196
Practice Address - Country:US
Practice Address - Phone:814-664-4641
Practice Address - Fax:814-664-8799
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051467207P00000X
PAOS010419L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA204624381CMedicaid
GA204624381CMedicaid
H71371Medicare UPIN