Basic Information
| Provider Information | |||||||||
| NPI: | 1346468204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 TAYLOR STREET | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039330288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1333 TAYLOR STREET | ||||||||
| Address2: | SUITE 3B | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039330288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | MATHEWS-BETTS | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8039330288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | 12184 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207RH0002X | 13924 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3812 | 05 | SC | MEDICAID |