Provider Demographics
NPI:1972707487
Name:GRISHAM, MATTHEW PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PAUL
Last Name:GRISHAM
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-220-7270
Practice Address - Fax:864-241-9211
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29867208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC298671Medicaid
SC298671Medicaid