Provider Demographics
NPI:1417174806
Name:GROSS FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:GROSS FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:803-531-2722
Mailing Address - Street 1:PO BOX 1442
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1442
Mailing Address - Country:US
Mailing Address - Phone:803-531-2722
Mailing Address - Fax:803-531-2743
Practice Address - Street 1:970 HOLLY ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4930
Practice Address - Country:US
Practice Address - Phone:803-531-2722
Practice Address - Fax:803-531-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT00617Medicaid
SCH41015Medicare UPIN