Provider Demographics
NPI:1427427335
Name:GRUMBLES, MADELEINE PRESSLEY (PA)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:PRESSLEY
Last Name:GRUMBLES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADELEINE
Other - Middle Name:CHERIE
Other - Last Name:PRESSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4285
Practice Address - Country:US
Practice Address - Phone:864-455-2888
Practice Address - Fax:864-455-2885
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2418363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2387PAMedicaid
SCSC67267951Medicare PIN