Basic Information
| Provider Information | |||||||||
| NPI: | 1780658146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSSMAN | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13320 N BOULEVARD ST | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490971514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696492012 | ||||||||
| FaxNumber: | 2696493752 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693418481 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KG080105 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 4301080105 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4893119 | 05 | MI | MEDICAID | CA2184 | 01 | MI | RAILROAD MEDICARE | OTHER |