Healthcare Provider Details

I. General information

NPI: 1285325431
Provider Name (Legal Business Name): JUSTIN ELLIS GROSSMAN FICHTNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W MAIN ST STE 204
LEXINGTON SC
29072-2500
US

IV. Provider business mailing address

145 SUNSET CT STE 100
WEST COLUMBIA SC
29169-2429
US

V. Phone/Fax

Practice location:
  • Phone: 803-358-6420
  • Fax: 803-358-6450
Mailing address:
  • Phone: 803-739-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90207
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: