=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174537021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH R GROSSMAN MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 580 COLLINS DR
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95348-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-383-0989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 COLLINS DR
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95348-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-383-0989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHYSICIAN
-----------------------------------------------------
Name | KENNETH RANDELL GROSSMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 209-383-0989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------