Provider Demographics
NPI:1952593964
Name:GROSSMAN, MICHELE ANN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ANN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHELE
Other - Middle Name:ANN
Other - Last Name:GENZLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:45 MAKAMAH BEACH RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1338
Mailing Address - Country:US
Mailing Address - Phone:631-678-8841
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:SOUTHSIDE HOSPITAL
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012144207P00000X
NY266690207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine