Healthcare Provider Details

I. General information

NPI: 1720057409
Provider Name (Legal Business Name): BRUCE J. GROSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 ROUTE 33
NEPTUNE NJ
07753-4859
US

IV. Provider business mailing address

1945 ROUTE 33
NEPTUNE NJ
07753-4859
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-3890
  • Fax: 732-776-2344
Mailing address:
  • Phone: 732-776-3890
  • Fax: 732-776-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number25MA06628000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: