Healthcare Provider Details

I. General information

NPI: 1639131485
Provider Name (Legal Business Name): KENNETH KOSCHNITZKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 COMMONWEALTH DR
GREENVILLE SC
29615-4812
US

IV. Provider business mailing address

101 ROCKBERRY TER
SIMPSONVILLE SC
29681-4766
US

V. Phone/Fax

Practice location:
  • Phone: 864-675-4414
  • Fax:
Mailing address:
  • Phone: 864-286-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number28286
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: