Provider Demographics
NPI:1841248085
Name:DE GROOD, ROBERT LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LOUIS
Last Name:DE GROOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-464-4000
Mailing Address - Fax:843-464-4017
Practice Address - Street 1:119 W LOWMAN ST
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-3107
Practice Address - Country:US
Practice Address - Phone:843-464-4000
Practice Address - Fax:843-464-4017
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17113174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1384Medicaid
SCAA89359493OtherMEDICARE
SCGP 9493OtherMEDICARE GROUP
SCGP 5462Medicaid
SCGP 5462Medicaid
SC5067Medicare ID - Type Unspecified