Healthcare Provider Details

I. General information

NPI: 1396760633
Provider Name (Legal Business Name): ELLEN SMITH GROSH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 HOGBACK RD STE 15
ANN ARBOR MI
48105-9752
US

IV. Provider business mailing address

3524 LARCHMONT DR
ANN ARBOR MI
48105-2854
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-0200
  • Fax: 734-971-1677
Mailing address:
  • Phone: 734-623-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301080927
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: