Provider Demographics
NPI:1063436749
Name:DOMINICK A. GROSSO, D.O. LLC
Entity type:Organization
Organization Name:DOMINICK A. GROSSO, D.O. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-219-0110
Mailing Address - Street 1:5 GLOBE CT
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1824
Mailing Address - Country:US
Mailing Address - Phone:732-219-0110
Mailing Address - Fax:732-212-8818
Practice Address - Street 1:5 GLOBE CT
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1824
Practice Address - Country:US
Practice Address - Phone:732-219-0110
Practice Address - Fax:732-212-8818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04501200207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2599954OtherGHI
NJ1485601Medicaid
NJ2599954OtherGHI
NJ092660Medicare PIN