=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033216577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC A. GROSSMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 W CENTRAL AVE #136
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92821-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-529-1421
-----------------------------------------------------
Fax | 714-256-0541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 W CENTRAL AVE #136
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-529-1421
-----------------------------------------------------
Fax | 714-256-0541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G42011
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------