Provider Demographics
NPI:1336364264
Name:CANTRELL, MATTHEW G (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:CANTRELL
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: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:803-296-7330
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-3800
Practice Address - Fax:803-744-2759
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064810A207R00000X, 208M00000X, 390200000X
SC35015207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200919560Medicaid
IN000000615180OtherANTHEM BCBS
SC350159Medicaid
SCAA94325729Medicare PIN
SCSC2667D311Medicare PIN
SC350159Medicaid
SCAA94329988Medicare PIN
IN000000615180OtherANTHEM BCBS
INM400015001Medicare PIN
IN940550N9Medicare PIN