Provider Demographics
NPI:1356527998
Name:NAOMI S GROBSTEIN
Entity type:Organization
Organization Name:NAOMI S GROBSTEIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-744-8511
Mailing Address - Street 1:48 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4137
Mailing Address - Country:US
Mailing Address - Phone:973-744-8511
Mailing Address - Fax:973-744-6356
Practice Address - Street 1:48 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4137
Practice Address - Country:US
Practice Address - Phone:973-744-8511
Practice Address - Fax:973-744-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03933400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ045401Medicare PIN