Healthcare Provider Details

I. General information

NPI: 1073142063
Provider Name (Legal Business Name): MATTHEW CHRISTIAN CAVINESS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST STE A
BLOOMINGTON IL
61704-3739
US

IV. Provider business mailing address

3349 MUD SPRING RD
ANDERSON MO
64831-1569
US

V. Phone/Fax

Practice location:
  • Phone: 309-300-1031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024009881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: