Healthcare Provider Details

I. General information

NPI: 1114366028
Provider Name (Legal Business Name): CHARLES KEVIN GRIGSBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 09/11/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S 8TH ST STE 301
GRIFFIN GA
30224-4260
US

IV. Provider business mailing address

619 S 8TH ST STE 301
GRIFFIN GA
30224-4260
US

V. Phone/Fax

Practice location:
  • Phone: 770-229-6072
  • Fax: 757-446-5197
Mailing address:
  • Phone: 770-229-6072
  • Fax: 757-446-5197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101265120
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: