Basic Information
| Provider Information | |||||||||
| NPI: | 1982894853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 W ILES AVE STE C | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177890668 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3050 MONTVALE DR STE A | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627046924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177268096 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20011001445 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 01070635A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 2007014745 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 01070635A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036132322 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201060170 | 05 | IN | MEDICAID |