Healthcare Provider Details

I. General information

NPI: 1972707487
Provider Name (Legal Business Name): MATTHEW PAUL GRISHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL RIDGE DRIVE
GREENVILLE SC
29605-4267
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-220-7270
  • Fax: 864-241-9211
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29867
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: