Basic Information
| Provider Information | |||||||||
| NPI: | 1720518384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUNDIFF | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVE RM 202 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437922575 | ||||||||
| FaxNumber: | 8437929295 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 RUTLEDGE AVE DEPT OF | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438761698 | ||||||||
| FaxNumber: | 8438761435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2017 | ||||||||
| LastUpdateDate: | 06/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | LL41060 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | LL41060 | 01 | SC | SOUTH CAROLINA BOARD OF MEDICAL EXAMINERS | OTHER |