Provider Demographics
NPI:1780658146
Name:GROSSMAN, KATHRYN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13320 N BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1514
Mailing Address - Country:US
Mailing Address - Phone:269-649-2012
Mailing Address - Fax:269-649-3752
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKG080105207Q00000X
MI4301080105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4893119Medicaid
MICA2184OtherRAILROAD MEDICARE
MICA2184OtherRAILROAD MEDICARE
MII37418Medicare UPIN