Healthcare Provider Details

I. General information

NPI: 1487093795
Provider Name (Legal Business Name): MATTHEW E SMETANA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N ROCKTON AVE
ROCKFORD IL
61103-3655
US

IV. Provider business mailing address

2400 N ROCKTON AVE
ROCKFORD IL
61103-3655
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-6510
  • Fax: 815-971-9860
Mailing address:
  • Phone: 815-971-6510
  • Fax: 815-971-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125.062920
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number65681-21
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036-139276
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: