Provider Demographics
NPI:1831305218
Name:HARRY GROSSMAN, MD
Entity type:Organization
Organization Name:HARRY GROSSMAN, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-983-1400
Mailing Address - Street 1:100 BRICK RD
Mailing Address - Street 2:115
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2146
Mailing Address - Country:US
Mailing Address - Phone:856-983-1400
Mailing Address - Fax:856-983-1681
Practice Address - Street 1:100 BRICK RD
Practice Address - Street 2:115
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2146
Practice Address - Country:US
Practice Address - Phone:856-983-1400
Practice Address - Fax:856-983-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65455332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3099717Medicaid
NJ3099717Medicaid