Basic Information
Provider Information | |||||||||
NPI: | 1902804198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRINSPUN | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 S WILLOW AVE | ||||||||
Address2: |   | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385014667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9315269518 | ||||||||
FaxNumber: | 9313720087 | ||||||||
Practice Location | |||||||||
Address1: | 105 S WILLOW AVE | ||||||||
Address2: |   | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385014667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9315269518 | ||||||||
FaxNumber: | 9313720087 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 16020 | MS | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 55872 | KY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | MD42863 | TN | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 4228439 | 01 | TN | BCBS OF TN | OTHER | 00760204 | 01 |   | MEDICARE RR | OTHER | 7835385 | 01 |   | AETNA | OTHER | 1514485 | 05 | TN |   | MEDICAID |