MEDICARE: FERN MARLA GROSSMAN D.C.

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	111N00000X	Chiropractor	DC006309L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2053318000	OTHER	PA	IBX

General Provider Information

NPI Number	:	1073689097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FERN MARLA GROSSMAN D.C.

Provider Business Mailing Address
First Line	:	1619 GRANT AVE
Second Line	:	GRANT PLAZA II
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3167
Country	:	US
Telephone Number	:	215-934-5401
Fax Number	:	215-934-5452

Provider Business Practice Location Address
First Line	:	1619 GRANT AVE
Second Line	:	GRANT PLAZA II
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-3167
Country	:	US
Telephone Number	:	215-934-5401
Fax Number	:	215-934-5452

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/08/2007

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