Healthcare Provider Details

I. General information

NPI: 1689672784
Provider Name (Legal Business Name): STEPHEN D. GRUBB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SEA MOUNTAIN HIGWAY SUITE C
LITTLE RIVER SC
29566
US

IV. Provider business mailing address

111 DOCTOR CIR
COLUMBIA SC
29203-6502
US

V. Phone/Fax

Practice location:
  • Phone: 843-399-4848
  • Fax: 910-653-2346
Mailing address:
  • Phone: 800-491-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22475
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7841
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: