MEDICARE: DR. MARK EDWARD GROMISCH M.D.

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	207RG0100X	Gastroenterology Physician	170354	NY

General Provider Information

NPI Number	:	1619092855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD GROMISCH M.D.

Provider Business Mailing Address
First Line	:	1005 SMITH RIDGE RD
Second Line	:
City	:	NEW CANAAN
State	:	CT
Zip	:	06840-2331
Country	:	US
Telephone Number	:	203-966-5682
Fax Number	:

Provider Business Practice Location Address
First Line	:	166 E 88TH ST
Second Line	:	SUITE 1
City	:	NEW YORK
State	:	NY
Zip	:	10128-2255
Country	:	US
Telephone Number	:	212-410-3350
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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