Healthcare Provider Details

I. General information

NPI: 1033191093
Provider Name (Legal Business Name): CLIFFORD N GROSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

PO BOX 200096
CARTERSVILLE GA
30120-9002
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-3000
  • Fax:
Mailing address:
  • Phone: 678-905-7053
  • Fax: 678-905-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number51576
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number51576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: