Provider Demographics
NPI:1063402014
Name:GROSSMAN, MARK GEOFFERY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GEOFFERY
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVE
Mailing Address - Street 2:SUITE UL3A
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1886
Mailing Address - Country:US
Mailing Address - Phone:516-747-8900
Mailing Address - Fax:516-663-8124
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:SUITE UL3A
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1886
Practice Address - Country:US
Practice Address - Phone:516-747-8900
Practice Address - Fax:516-663-8124
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224563207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02359162Medicaid
NY1063402014Medicare NSC
NY02359162Medicaid