Healthcare Provider Details

I. General information

NPI: 1851424865
Provider Name (Legal Business Name): PAUL MITCHELL GROSSBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 UNIVERSITY AVE
MADISON WI
53726-4084
US

IV. Provider business mailing address

5905 HEMPSTEAD RD
MADISON WI
53711-3346
US

V. Phone/Fax

Practice location:
  • Phone: 608-262-9200
  • Fax: 608-262-9160
Mailing address:
  • Phone: 608-274-9422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19988
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: