Healthcare Provider Details

I. General information

NPI: 1568778991
Provider Name (Legal Business Name): CARLA ANDREA GROSSOLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 13TH AVE S
FARGO ND
58103-3602
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3620
  • Fax:
Mailing address:
  • Phone: 605-328-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16721
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125058734
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14139
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036132748
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: