=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114366028
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES KEVIN GRIGSBY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2013
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 S 8TH ST STE 301
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30224-4260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-229-6072
-----------------------------------------------------
Fax | 757-446-5197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 S 8TH ST STE 301
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30224-4260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-229-6072
-----------------------------------------------------
Fax | 757-446-5197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | 0101265120
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------