=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942692058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELVIN M. GROSSMAN, M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2015
-----------------------------------------------------
Last Update Date | 02/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 SHERIDAN ST SUITE U
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-962-6333
-----------------------------------------------------
Fax | 954-963-2442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 SHERIDAN ST SUITE U
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-962-6333
-----------------------------------------------------
Fax | 954-963-2442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. MELVIN M GROSSMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-962-6333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0402X
-----------------------------------------------------
Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
-----------------------------------------------------
License Number | FLME0041670
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | FLME0041670
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------