Healthcare Provider Details

I. General information

NPI: 1043218837
Provider Name (Legal Business Name): MATTHEW TOLMAN STEDELIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S LINCOLN BLVD
CENTRALIA IL
62801-3654
US

IV. Provider business mailing address

130 S LINCOLN BLVD
CENTRALIA IL
62801-3654
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-3604
  • Fax: 618-532-2952
Mailing address:
  • Phone: 618-532-3604
  • Fax: 618-532-2952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: