Provider Demographics
NPI:1538158233
Name:GROSSMAN, MICHAEL R (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:580-249-3003
Mailing Address - Fax:580-599-6447
Practice Address - Street 1:330 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5825
Practice Address - Country:US
Practice Address - Phone:580-249-3003
Practice Address - Fax:580-599-6447
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10463207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1E4684OtherPTAN
OK100013500AMedicaid