Provider Demographics
NPI:1891133799
Name:BRADSHAW, MATTHEW HAYNIE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HAYNIE
Last Name:BRADSHAW
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 1:2000 E GREENVILLE ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1580
Mailing Address - Country:US
Mailing Address - Phone:864-224-1055
Mailing Address - Fax:864-224-3773
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1580
Practice Address - Country:US
Practice Address - Phone:864-224-1055
Practice Address - Fax:864-224-3773
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC359034Medicaid