MEDICARE: MILTON J GROSENBACH EDD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	4101005216	MI
2	103T00000X	Psychologist	6301003782	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0M43200	OTHER	MI	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	OD41119	OTHER	MI	BLUE CARE NETWORK
3	0D41076	OTHER	MI	BLUE CROSS BLUE SHIELD
4	620G44601	OTHER	MI	HEALTH PLUS

General Provider Information

NPI Number	:	1821135831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILTON J GROSENBACH EDD, PC

Provider Business Mailing Address
First Line	:	3562 S LAPEER RD
Second Line	:	SUITE F
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:	810-678-8898
Fax Number	:	810-678-8808

Provider Business Practice Location Address
First Line	:	3562 S LAPEER RD
Second Line	:	SUITE F
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:	810-678-8898
Fax Number	:	810-678-8808

Authorized Official
Title or Position	:	DR OWNER
Name	:	DR. MILTON JAMES GROSENBACH JR.
Credential	:	EDD PC
Telephone Number	:	810-678-8898

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	06/27/2016

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Directions to “MILTON J GROSENBACH EDD, PC ” Practice Location

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