Provider Demographics
NPI:1952543316
Name:MICHAEL JACK GROSSMAN, M.D., INC
Entity Type:Organization
Organization Name:MICHAEL JACK GROSSMAN, M.D., INC
Other - Org Name:BODYLOGICMD OF IRVINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-222-0232
Mailing Address - Street 1:4440 VON KARMAN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-222-0232
Mailing Address - Fax:949-222-0344
Practice Address - Street 1:4440 VON KARMAN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-222-0232
Practice Address - Fax:949-222-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty