Healthcare Provider Details

I. General information

NPI: 1083961114
Provider Name (Legal Business Name): GROSS FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

IV. Provider business mailing address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-2722
  • Fax: 803-531-2743
Mailing address:
  • Phone: 803-531-2722
  • Fax: 803-531-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0646
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VERDELL F HAYGOOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-531-2722