Healthcare Provider Details

I. General information

NPI: 1558556753
Provider Name (Legal Business Name): GARY RICHARD GROMACK MED CCC A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 HAMBURG TPKE STE 104
WAYNE NJ
07470
US

IV. Provider business mailing address

601 HAMBURG TPKE STE 104
WAYNE NJ
07470-2049
US

V. Phone/Fax

Practice location:
  • Phone: 862-257-1370
  • Fax:
Mailing address:
  • Phone: 862-257-1370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number25MG00049600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0007561
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number41YA00007600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number41YA000076
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: