Provider Demographics
NPI:1902804198
Name:GRINSPUN, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:GRINSPUN
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 1:105 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4667
Mailing Address - Country:US
Mailing Address - Phone:931-526-9518
Mailing Address - Fax:931-372-0087
Practice Address - Street 1:105 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4667
Practice Address - Country:US
Practice Address - Phone:931-526-9518
Practice Address - Fax:931-372-0087
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16020207X00000X
KY55872207X00000X
TNMD42863207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4228439OtherBCBS OF TN
00760204OtherMEDICARE RR
7835385OtherAETNA
TN1514485Medicaid
00760204OtherMEDICARE RR
7835385OtherAETNA