Basic Information
| Provider Information | |||||||||
| NPI: | 1619952371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROSSMAN | ||||||||
| FirstName: | COLBY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695879 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 OAKBROOK LN | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294858215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438512000 | ||||||||
| FaxNumber: | 8438512003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12448 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 124485 | 05 | SC | MEDICAID | 1649422296 | 01 | SC | NPI SITE ID# | OTHER |