Provider Demographics
NPI:1720511074
Name:GROSSMAN, SHOSHANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOSHANA
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHOSHANA
Other - Middle Name:
Other - Last Name:KORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:222 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1822
Mailing Address - Country:US
Mailing Address - Phone:516-508-0281
Mailing Address - Fax:
Practice Address - Street 1:200 N 16TH ST STE D
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1225
Practice Address - Country:US
Practice Address - Phone:215-315-3197
Practice Address - Fax:215-689-4466
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PAMT213672207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program