Healthcare Provider Details

I. General information

NPI: 1720076078
Provider Name (Legal Business Name): JEANNE THERESE GROSSMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 HOSPITAL DR NW STE 250
CORYDON IN
47112-2176
US

IV. Provider business mailing address

1263 HOSPITAL DR NW STE 250
CORYDON IN
47112-2176
US

V. Phone/Fax

Practice location:
  • Phone: 812-738-8136
  • Fax: 812-738-3155
Mailing address:
  • Phone: 812-738-8136
  • Fax: 812-738-3155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01049002A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: