1609820372 NPI number — DR. IRINA GROSMAN M.D.

Table of content: DR. IRINA GROSMAN M.D. (NPI 1609820372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609820372 NPI number — DR. IRINA GROSMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSMAN
Provider First Name:
IRINA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609820372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 N OCEAN BLVD APT 1501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33062-5153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-400-0405
Provider Business Mailing Address Fax Number:
954-785-3142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4725 N FEDERAL HWY
Provider Second Line Business Practice Location Address:
HOLY CROSS HOSPITAL DEPARTMENT OF RADIATION
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-4603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-492-5764
Provider Business Practice Location Address Fax Number:
954-776-3238
Provider Enumeration Date:
05/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0203X , with the licence number:  ME 71096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0203X , with the licence number: 25MA06449800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: 196838-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: MD058312L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2743841 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007514700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".