Provider Demographics
NPI:1205892783
Name:CAROLINA RETINA CENTER P.A.
Entity type:Organization
Organization Name:CAROLINA RETINA CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-736-7200
Mailing Address - Street 1:7620 TRENHOLM ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1718
Mailing Address - Country:US
Mailing Address - Phone:803-736-7200
Mailing Address - Fax:803-736-2116
Practice Address - Street 1:7620 TRENHOLM ROAD EXT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1718
Practice Address - Country:US
Practice Address - Phone:803-736-7200
Practice Address - Fax:803-736-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1780Medicaid
SCGP1780Medicaid