Provider Demographics
NPI:1184670994
Name:KISSENBERTH, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KISSENBERTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604348
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 CONGAREE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3519
Practice Address - Country:US
Practice Address - Phone:864-248-4100
Practice Address - Fax:864-248-4105
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27259207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863158OtherBCBS OF SC
SC7422707OtherAETNA
SC7359182OtherCIGNA
SC272591Medicaid
SC576007863133OtherBLUE CHOICE OF SC
SCP00271214OtherRR MEDICARE
SC7422707OtherAETNA
SC576007863133OtherBLUE CHOICE OF SC
SCI238468299Medicare PIN