Healthcare Provider Details

I. General information

NPI: 1467438853
Provider Name (Legal Business Name): RACHAEL E GROSS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

IV. Provider business mailing address

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 Number646
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: