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General NPI Number Information
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NPI Number | 1942492475
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Entity Type | Individual
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Provider Name | CHARLES SMITTKAMP M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/17/2007
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 800 E CARPENTER ST
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City | SPRINGFIELD
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State | IL
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Zip | 62769-1901
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Country | US
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Telephone | 217-544-6464
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Fax |
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Provider Business Mailing Address
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Address Line | 111 OAKWOOD RD
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City | EAST PEORIA
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State | IL
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Zip | 61611-1853
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Country | US
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Telephone | 97-404-2723
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 125-052437
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | 40110
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | 036125189
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License Number State | IL
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