Organization
GROSS FAMILY PRACTICE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VERDELL F HAYGOOD (OFFICE MANAGER)
(803) 531-2722
Entity
Organization
Contact information
Practice address
970 HOLLY ST, ORANGEBURG, SC 29115-4930
(803) 531-2722
(803) 531-2743
Mailing address
970 HOLLY ST, ORANGEBURG, SC 29115-4930
(803) 531-2722
(803) 531-2743
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
0646
SC
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
H410155677
MEDICARE ID
SC
05
—
T00617
—
SC
Enumeration date
08/08/2012
Last updated
09/21/2012
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