Healthcare Provider Details

I. General information

NPI: 1750387627
Provider Name (Legal Business Name): ZACHARY GROSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7664 STONEHEDGE LANE
MANILUS NY
13104-0001
US

IV. Provider business mailing address

7664 STONEHEDGE LANE
MANILUS NY
13104-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number118782
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier00714085
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: