Healthcare Provider Details

I. General information

NPI: 1013986991
Provider Name (Legal Business Name): MARY ELLEN GROFF APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 OKATIE CTR BLVD STE 100
BLUFFTON SC
29909-7519
US

IV. Provider business mailing address

AGAPE SENIOR PRIMARY CARE INC 1624 MAIN STREET
COLUMBIA SC
29201-2818
US

V. Phone/Fax

Practice location:
  • Phone: 843-708-8888
  • Fax: 843-705-7024
Mailing address:
  • Phone: 803-726-2350
  • Fax: 803-753-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR04165
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3789
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: