Healthcare Provider Details

I. General information

NPI: 1659494482
Provider Name (Legal Business Name): IRENA GRIBOVSKAJA-RUPP M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRENA GRIBOVSKAJA M.D.

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 TAYLOR ST STE 5F
COLUMBIA SC
29201-2951
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-748-9966
  • Fax: 803-749-7174
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD-42736
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD-42736
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number92626
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: