MEDICARE: MR. RICHARD GROSSMAN BA

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1063695112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD GROSSMAN BA

Provider Business Mailing Address
First Line	:	4209 SW MCCLELLEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6135
Country	:	US
Telephone Number	:	772-336-7516
Fax Number	:	772-336-7516

Provider Business Practice Location Address
First Line	:	4209 SW MCCLELLEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6135
Country	:	US
Telephone Number	:	772-336-7516
Fax Number	:	772-336-7516

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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