Provider Demographics
NPI:1972565513
Name:GROSSMAN, SAMUEL L (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:L
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 1:181 W EMMETT ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49037-2963
Mailing Address - Country:US
Mailing Address - Phone:269-966-2600
Mailing Address - Fax:269-965-4773
Practice Address - Street 1:181 W EMMETT ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-2963
Practice Address - Country:US
Practice Address - Phone:269-966-2600
Practice Address - Fax:269-965-4773
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4461230Medicaid
MI3368240Medicaid
MI4461230Medicaid
A36090011Medicare ID - Type Unspecified