Provider Demographics
NPI:1992966477
Name:CAROLINA MACULAR AND RETINAL CARE LLC
Entity type:Organization
Organization Name:CAROLINA MACULAR AND RETINAL CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-724-3456
Mailing Address - Street 1:613 LONG POINT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8350
Mailing Address - Country:US
Mailing Address - Phone:843-724-3456
Mailing Address - Fax:843-724-3455
Practice Address - Street 1:613 LONG POINT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8350
Practice Address - Country:US
Practice Address - Phone:843-724-3456
Practice Address - Fax:843-724-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29610207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4917Medicaid
SC9104Medicare PIN