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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X22475NCN Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X7841SCY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
56124396201SCBCBSOTHER
036301NCCIGNA MEDICAREOTHER
890291H05NC MEDICAID
E1611305SC MEDICAID
595017605NC MEDICAID
231506901NCCIGNA MEDICAREOTHER
595065305NC MEDICAID
57094162901SCBCBSOTHER
CA998001NCRAILROAD MEDICAREOTHER


Home