Basic Information
Provider Information | |||||||||
NPI: | 1689672784 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRUBB | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 DOCTOR CIR | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292036502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004910909 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3600 SEA MOUNTAIN HIGWAY | ||||||||
Address2: | SUITE C | ||||||||
City: | LITTLE RIVER | ||||||||
State: | SC | ||||||||
PostalCode: | 29566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433994848 | ||||||||
FaxNumber: | 9106532346 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22475 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 7841 | SC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 561243962 | 01 | SC | BCBS | OTHER | 0363 | 01 | NC | CIGNA MEDICARE | OTHER | 890291H | 05 | NC |   | MEDICAID | E16113 | 05 | SC |   | MEDICAID | 5950176 | 05 | NC |   | MEDICAID | 2315069 | 01 | NC | CIGNA MEDICARE | OTHER | 5950653 | 05 | NC |   | MEDICAID | 570941629 | 01 | SC | BCBS | OTHER | CA9980 | 01 | NC | RAILROAD MEDICARE | OTHER |