MEDICARE: FRED GROSSMAN, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	16458	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043483589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED GROSSMAN, MD

Provider Business Mailing Address
First Line	:	4200 W CONEJOS PL
Second Line	:	SUITE 536
City	:	DENVER
State	:	CO
Zip	:	80204-1333
Country	:	US
Telephone Number	:	303-571-1355
Fax Number	:	303-571-1520

Provider Business Practice Location Address
First Line	:	4200 W CONEJOS PL
Second Line	:	SUITE 536
City	:	DENVER
State	:	CO
Zip	:	80204-1333
Country	:	US
Telephone Number	:	303-571-1355
Fax Number	:	303-571-1520

Authorized Official
Title or Position	:	OWNER
Name	:	FRED GROSSMAN
Credential	:	MD
Telephone Number	:	303-571-1355

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	04/10/2008

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