Healthcare Provider Details

I. General information

NPI: 1598116469
Provider Name (Legal Business Name): TREVOR S GRAVELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HERLONG AVE S STE G
ROCK HILL SC
29732-1182
US

IV. Provider business mailing address

200 HERLONG AVE S STE G
ROCK HILL SC
29732-1182
US

V. Phone/Fax

Practice location:
  • Phone: 803-909-6300
  • Fax: 803-909-6310
Mailing address:
  • Phone: 803-909-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME151950
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME151950
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME151950
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME151950
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number90083
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: