Basic Information
| Provider Information | |||||||||
| NPI: | 1043298334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | TRENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 MAYO DR | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096725700 | ||||||||
| FaxNumber: | 3096712774 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | DEPARTMENT OF RADIATION ONCOLOGY | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096725700 | ||||||||
| FaxNumber: | 3096712774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | M2918 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 036.126216 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 202746801 | 05 | TX | MEDICAID |