Provider Demographics
NPI:1720057409
Name:GROSSMAN, BRUCE J (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 ROUTE 33
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4859
Mailing Address - Country:US
Mailing Address - Phone:732-776-3890
Mailing Address - Fax:732-776-2344
Practice Address - Street 1:1945 ROUTE 33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4859
Practice Address - Country:US
Practice Address - Phone:732-776-3890
Practice Address - Fax:732-776-2344
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA066280002080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHH70029Medicare UPIN