Healthcare Provider Details

I. General information

NPI: 1518459486
Provider Name (Legal Business Name): ANNA STEPHANIE KOOKOOLIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 VINECREST CT # 1000
GREENWOOD SC
29646-8031
US

IV. Provider business mailing address

104 WELLS AVE
GREENWOOD SC
29646-3837
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-3350
  • Fax: 864-725-3351
Mailing address:
  • Phone: 864-725-4673
  • Fax: 864-725-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT215736
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number91385
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: