Provider Demographics
NPI:1457436347
Name:GRUICH, CHARLES J (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:GRUICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2356 PASS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2236
Mailing Address - Country:US
Mailing Address - Phone:228-388-7080
Mailing Address - Fax:228-388-7493
Practice Address - Street 1:2356 PASS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2236
Practice Address - Country:US
Practice Address - Phone:228-388-7080
Practice Address - Fax:228-388-7493
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS08349320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08349OtherLIC.#
MSAG8063149OtherDEA
MSC48139Medicare UPIN