Provider Demographics
NPI:1689702698
Name:WUNDERLICH, COLLEEN ANN (MD, MSC)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:ANN
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:803-296-7320
Mailing Address - Fax:803-293-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7995
Practice Address - Fax:803-434-8686
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00969208100000X, 2081P0010X
MN46317208100000X
VA01012383042081P0010X
SC406162081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907606Medicaid
SCN69007Medicaid
NC1458XOtherNCBCBS
SCN69007Medicaid