Basic Information
| Provider Information | |||||||||
| NPI: | 1568414977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSSMAN | ||||||||
| FirstName: | NEIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 STILES RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030792846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038904404 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 366 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024816206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812390033 | ||||||||
| FaxNumber: | 7812378938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 01/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 44509 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 6164099 | 05 | MA | MEDICAID |