Healthcare Provider Details

I. General information

NPI: 1578715850
Provider Name (Legal Business Name): ANNA LEAH GROSSBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

PO BOX 64252
BALTIMORE MD
21264-4252
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-5767
  • Fax:
Mailing address:
  • Phone: 410-328-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD74040
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberD74040
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: