MEDICARE: JEREMY IAN GROSSER, M.D., INC.

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	261QM2500X	Medical Specialty Clinic/Center	A67128	CA

General Provider Information

NPI Number	:	1174702377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEREMY IAN GROSSER, M.D., INC.

Provider Business Mailing Address
First Line	:	109 DAPPLEGRAY RD
Second Line	:
City	:	BELL CANYON
State	:	CA
Zip	:	91307-1050
Country	:	US
Telephone Number	:	818-929-2259
Fax Number	:	818-700-5690

Provider Business Practice Location Address
First Line	:	7355 TOPANGA CANYON BLVD STE 200
Second Line	:
City	:	CANOGA PARK
State	:	CA
Zip	:	91303-1244
Country	:	US
Telephone Number	:	818-885-8500
Fax Number	:	818-700-5690

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEREMY IAN GROSSER
Credential	:	MD
Telephone Number	:	818-929-2259

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	09/04/2022

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