MEDICARE: MICHAEL JACK GROSSMAN, M.D., INC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1952543316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL JACK GROSSMAN, M.D., INC

Provider Business Mailing Address
First Line	:	4440 VON KARMAN AVE
Second Line	:	SUITE 201
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660
Country	:	US
Telephone Number	:	949-222-0232
Fax Number	:	949-222-0344

Provider Business Practice Location Address
First Line	:	4440 VON KARMAN AVE
Second Line	:	SUITE 201
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660
Country	:	US
Telephone Number	:	949-222-0232
Fax Number	:	949-222-0344

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL JACK GROSSMAN
Credential	:	M.D.
Telephone Number	:	949-222-0232

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	05/06/2020

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