Provider Demographics
NPI:1720076078
Name:GROSSMAN, JEANNE THERESE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:THERESE
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 HOSPITAL DR NW STE 250
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2176
Mailing Address - Country:US
Mailing Address - Phone:812-738-8136
Mailing Address - Fax:812-738-3155
Practice Address - Street 1:1263 HOSPITAL DR NW STE 250
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2176
Practice Address - Country:US
Practice Address - Phone:812-738-8136
Practice Address - Fax:812-738-3155
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049002A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00202390OtherRR MEDICARE
IN200239440Medicaid
IN000000335249OtherANTHEM
INP00202390OtherRR MEDICARE
IN940190BBBBMedicare ID - Type Unspecified