Basic Information
| Provider Information | |||||||||
| NPI: | 1689221590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSMAN | ||||||||
| FirstName: | IGOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570 SOUTH AVE E UNIT A | ||||||||
| Address2: | |||||||||
| City: | CRANFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070163200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082727990 | ||||||||
| FaxNumber: | 9082727970 | ||||||||
| Practice Location | |||||||||
| Address1: | 570 SOUTH AVE E UNIT A | ||||||||
| Address2: | |||||||||
| City: | CRANFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070163200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082727990 | ||||||||
| FaxNumber: | 9082727990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2019 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.