Provider Demographics
NPI:1114997095
Name:GRANT, KENNETH FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:FRED
Last Name:GRANT
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 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1 SCIENCE CT
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9344
Practice Address - Country:US
Practice Address - Phone:803-252-1913
Practice Address - Fax:803-252-2330
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21834174400000X, 207ZP0102X, 207ZB0001X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT59228Medicaid
SCT59228Medicaid
SC220032401Medicare PIN
SCF00390Medicare UPIN