Healthcare Provider Details

I. General information

NPI: 1477580462
Provider Name (Legal Business Name): MICHAEL D GROSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MILL RD
FAIRHAVEN MA
02719-5208
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-2204
  • Fax: 508-973-2640
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number278809
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number265457-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: