=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194770115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH RUSSELL GROSSLIGHT MD JD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 07/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3227 SUNSET BLVD # F SUITE 102
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-724-2336
-----------------------------------------------------
Fax | 803-724-2317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3227-F SUNSET BLVD SUITE 102
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-724-2336
-----------------------------------------------------
Fax | 803-724-2317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 0101036844
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 12719
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------