Provider Demographics
NPI:1740263276
Name:GROSSBARD, MICHAEL L (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:GROSSBARD
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:PO BOX 95000-2467
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2467
Mailing Address - Country:US
Mailing Address - Phone:212-256-3539
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE FL 11
Practice Address - Street 2:SUITE 11C02
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:212-523-5419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216357207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02052808Medicaid
NY839001Medicare ID - Type Unspecified
NY02052808Medicaid