Provider Demographics
NPI:1023068897
Name:GROSSMAN, WILLIAM J (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 RUTLEDGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403
Mailing Address - Country:US
Mailing Address - Phone:843-723-1614
Mailing Address - Fax:843-727-2980
Practice Address - Street 1:191 RUTLEDGE AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-723-1614
Practice Address - Fax:843-727-2980
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6926207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC069268Medicaid
SC069268Medicaid
SCD05558Medicare UPIN