Provider Demographics
NPI:1770527715
Name:GROSSMAN, NEIL J (MD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:J
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:BMC PROVIDER ENROLLMENT OFFICE
Mailing Address - Street 2:960 MASSACHUSETTS AVE,.2ND FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVE.
Practice Address - Street 2:CROSSTOWN BLDG FL 7
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-04-04
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Provider Licenses
StateLicense IDTaxonomies
MA238502208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110081553AMedicaid