Basic Information
| Provider Information | |||||||||
| NPI: | 1356791735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELTHALER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
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| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1730 SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 679 | SC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | PD6791 | 05 | SC | MEDICAID |