Provider Demographics
NPI:1538144704
Name:GROSSMAN, MARVIN N (DPM)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:N
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4271
Mailing Address - Country:US
Mailing Address - Phone:330-494-2700
Mailing Address - Fax:330-494-6898
Practice Address - Street 1:1266 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4271
Practice Address - Country:US
Practice Address - Phone:330-494-2700
Practice Address - Fax:330-494-6898
Is Sole Proprietor?:No
Enumeration Date:2005-12-10
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001528213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0162005Medicaid
OH4389870001OtherADMINISTAR DMERC B
OH4389870001Medicare NSC
OH0162005Medicaid
OHT80348Medicare UPIN