Healthcare Provider Details

I. General information

NPI: 1184670994
Provider Name (Legal Business Name): MICHAEL JOHN KISSENBERTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CONGAREE RD
GREENVILLE SC
29607-3519
US

IV. Provider business mailing address

PO BOX 604348
CHARLOTTE NC
28260-4348
US

V. Phone/Fax

Practice location:
  • Phone: 864-248-4100
  • Fax: 864-248-4105
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number27259
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number27259
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: