Healthcare Provider Details

I. General information

NPI: 1417174806
Provider Name (Legal Business Name): GROSS FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

IV. Provider business mailing address

PO BOX 1442
ORANGEBURG SC
29116-1442
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 TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RACHAEL E GROSS
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 803-531-2722