Provider Demographics
NPI:1467438853
Name:GROSS, RACHAEL E (DO)
Entity Type:Individual
Prefix:DR
First Name:RACHAEL
Middle Name:E
Last Name:GROSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT00617Medicaid
SCH410155677Medicare ID - Type Unspecified
SCH41015Medicare UPIN