Healthcare Provider Details

I. General information

NPI: 1942492475
Provider Name (Legal Business Name): CHARLES SMITTKAMP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1901
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-6464
  • Fax:
Mailing address:
  • Phone: 97-404-2723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125-052437
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number40110
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036125189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: