Healthcare Provider Details

I. General information

NPI: 1962082420
Provider Name (Legal Business Name): MADISON MCKINNEY FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL RIDGE DR
GREENVILLE SC
29605-4267
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-5220
  • Fax: 864-522-5296
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number86033
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: