Provider Demographics
NPI:1740371970
Name:GROSSMAN, IRA C (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:C
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 1:670 S RIVER ST STE 301
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1032
Mailing Address - Country:US
Mailing Address - Phone:570-270-2600
Mailing Address - Fax:570-270-2828
Practice Address - Street 1:670 S RIVER ST STE 301
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1032
Practice Address - Country:US
Practice Address - Phone:570-270-2600
Practice Address - Fax:570-270-2828
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018268E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007116840001Medicaid
PA152132KPHMedicare ID - Type Unspecified
PA0007116840001Medicaid