Provider Demographics
NPI:1013986991
Name:GROFF, MARY ELLEN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:GROFF
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AGAPE SENIOR PRIMARY CARE INC
Mailing Address - Street 2:1624 MAIN STREET
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2818
Mailing Address - Country:US
Mailing Address - Phone:803-726-2350
Mailing Address - Fax:803-753-9102
Practice Address - Street 1:40 OKATIE CTR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7519
Practice Address - Country:US
Practice Address - Phone:843-708-8888
Practice Address - Fax:843-705-7024
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR04165363L00000X
SC3789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD121922400Medicaid
SCNP1602Medicaid
MD089L 184WMedicare ID - Type Unspecified
MD121922400Medicaid