Healthcare Provider Details

I. General information

NPI: 1427012533
Provider Name (Legal Business Name): KENNETH A GROSSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WHITE RD SUITE 103
LITTLE SILVER NJ
07739-1166
US

IV. Provider business mailing address

180 WHITE RD SUITE 103
LITTLE SILVER NJ
07739-1166
US

V. Phone/Fax

Practice location:
  • Phone: 732-842-5222
  • Fax: 732-741-6285
Mailing address:
  • Phone: 732-842-5222
  • Fax: 732-741-6285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number25MA04207000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: