MEDICARE: DR. MILTON JAMES GROSENBACH JR. EDD PC

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	103T00000X	Psychologist	6301003782	MI
2	106H00000X	Marriage & Family Therapist	4101005216	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0M43200	OTHER	MI	MEDICARE
3	OM43200	OTHER	MI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	620G44601	OTHER	MI	HEALTHPLUS
4	680D44501	OTHER	MI	BLUECROSS/BLUESHIELD

General Provider Information

NPI Number	:	1851392310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MILTON JAMES GROSENBACH JR. EDD PC

Provider Business Mailing Address
First Line	:	3562 S LAPEER RD STE F
Second Line	:
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:	810-678-8898
Fax Number	:	810-668-8808

Provider Business Practice Location Address
First Line	:	3562 S LAPEER RD STE F
Second Line	:
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:	810-678-8898
Fax Number	:	810-668-8808

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/28/2015

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Directions to “ DR. MILTON JAMES GROSENBACH JR. EDD PC” Practice Location

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