Basic Information
| Provider Information | |||||||||
| NPI: | 1811125909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMBRELL | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BRADLEY | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 CLEMSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292294341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Practice Location | |||||||||
| Address1: | 4568 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290729250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035205144 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116021830 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 0101251800 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.