Healthcare Provider Details

I. General information

NPI: 1245195783
Provider Name (Legal Business Name): MATT R SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1000
US

IV. Provider business mailing address

2019 FOX HVN
CHATHAM IL
62629-4411
US

V. Phone/Fax

Practice location:
  • Phone: 815-280-9937
  • Fax:
Mailing address:
  • Phone: 815-209-9937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number05128656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: