Provider Demographics
NPI:1255340790
Name:GROSSMAN, JAMES G (PAC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605
Mailing Address - Country:US
Mailing Address - Phone:207-664-5304
Mailing Address - Fax:207-664-5305
Practice Address - Street 1:32 RESORT WAY
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-664-5480
Practice Address - Fax:207-664-5490
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME297720099Medicaid
ME297720099Medicaid
MEAP063702Medicare PIN
MEAP063701Medicare PIN
S09514Medicare UPIN
AP0637Medicare PIN