Basic Information
| Provider Information | |||||||||
| NPI: | 1063484442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROBMAN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1602 NEWPORT GAP PIKE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198086208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026335840 | ||||||||
| FaxNumber: | 3026335844 | ||||||||
| Practice Location | |||||||||
| Address1: | 3411 SILVERSIDE RD | ||||||||
| Address2: | WELDIN BUILDING SUITE 102 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024790580 | ||||||||
| FaxNumber: | 3024790583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C2-0003657 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0000318803 | 05 | DE | MEDICAID | 510334650 | 01 | DE | BCBS OF DE | OTHER | 08D0876971 | 01 | DE | CLIA | OTHER | 110044275 | 01 | DE | RRM | OTHER |