Healthcare Provider Details

I. General information

NPI: 1215016662
Provider Name (Legal Business Name): MICHAEL SAMUEL GROSSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 N ROCKWOOD DR
PEORIA IL
61615-3803
US

IV. Provider business mailing address

3602 MARQUETTE RD
PERU IL
61354-1450
US

V. Phone/Fax

Practice location:
  • Phone: 309-589-1880
  • Fax:
Mailing address:
  • Phone: 815-223-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number202629
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036128242
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29207
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036128242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: