Provider Demographics
NPI:1104855089
Name:WIENECKE, MATTHEW M (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:M
Last Name:WIENECKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 200A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7940
Practice Address - Fax:803-434-2262
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC143812080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC143810Medicaid
SC143810Medicaid
SCF693492389Medicare PIN