Provider Demographics
NPI:1265594758
Name:GROSSMAN, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 S 4TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:888-977-2109
Practice Address - Street 1:GREAT LAKES RECOVERY CENTERS, INC.
Practice Address - Street 2:104 MALTON ROAD
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866
Practice Address - Country:US
Practice Address - Phone:906-228-4692
Practice Address - Fax:906-228-2830
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039616207Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080119915OtherRRMEDICARE
MI103306416Medicaid
MIMG039616OtherBCBS LICENSE
MIB47766Medicare UPIN
MI103306416Medicaid