Healthcare Provider Details

I. General information

NPI: 1033135991
Provider Name (Legal Business Name): GEORGE T GROSSBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

1438 S GRAND BLVD PROVIDER ENROLLMENT
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4829
  • Fax: 314-268-5494
Mailing address:
  • Phone: 314-977-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberR6957
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR6957
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: