Provider Demographics
NPI:1194770115
Name:GROSSLIGHT, KENNETH RUSSELL (MD JD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RUSSELL
Last Name:GROSSLIGHT
Suffix:
Gender:M
Credentials:MD JD
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3227-F SUNSET BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3201
Mailing Address - Country:US
Mailing Address - Phone:803-724-2336
Mailing Address - Fax:803-724-2317
Practice Address - Street 1:3227 SUNSET BLVD # F
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3201
Practice Address - Country:US
Practice Address - Phone:803-724-2336
Practice Address - Fax:803-724-2317
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101036844207L00000X
SC12719208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC127197Medicaid
SC3956Medicare UPIN