Basic Information
| Provider Information | |||||||||
| NPI: | 1336364264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343800 | ||||||||
| FaxNumber: | 8037442759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01064810A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 01064810A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 01064810A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 35015 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200919560 | 05 | IN | MEDICAID | 350159 | 05 | SC | MEDICAID | 000000615180 | 01 | IN | ANTHEM BCBS | OTHER |