Provider Demographics
NPI:1619952371
Name:GROSSMAN, COLBY H (MD)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:H
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
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 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:201 OAKBROOK LN
Practice Address - Street 2:SUITE 255
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8215
Practice Address - Country:US
Practice Address - Phone:843-851-2000
Practice Address - Fax:843-851-2003
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC124485Medicaid
SC1649422296OtherNPI SITE ID#
SCB92031Medicare UPIN
SCB920317006Medicare PIN
SC124485Medicaid
SC1649422296OtherNPI SITE ID#