=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306816251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH COUNTY PRIMARY CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 KINGSTOWN RD SUITE 104
-----------------------------------------------------
City | NARRAGANSETT
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02882-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-789-1086
-----------------------------------------------------
Fax | 401-789-5344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 KINGSTOWN RD SUITE 104
-----------------------------------------------------
City | NARRAGANSETT
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02882-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-789-1086
-----------------------------------------------------
Fax | 401-789-5344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MONICA LOUISE GROSS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 401-789-1086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD09154
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------