Healthcare Provider Details

I. General information

NPI: 1053686683
Provider Name (Legal Business Name): ROBERT T GROSSMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7073 CLYO RD
CENTERVILLE OH
45459-4816
US

IV. Provider business mailing address

36123 SCHOOLCRAFT RD
LIVONIA MI
48150-1216
US

V. Phone/Fax

Practice location:
  • Phone: 937-435-5857
  • Fax: 937-912-4960
Mailing address:
  • Phone: 734-464-0887
  • Fax: 734-402-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35074438
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: