Provider Demographics
NPI:1215027438
Name:CHENAULT, MATTHEW RAY (D C)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RAY
Last Name:CHENAULT
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 VESCI AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2925
Mailing Address - Country:US
Mailing Address - Phone:618-659-1699
Mailing Address - Fax:
Practice Address - Street 1:1105 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-2221
Practice Address - Country:US
Practice Address - Phone:618-664-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009435111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009435Medicaid
IL51316OtherCIGNA
IL0332010OtherBCBS
IL412192761OtherTAX ID
ILP00287309OtherRR MEDICARE
IL109433OtherGHP
IL466637OtherHEALTHLINK
ILDE3519OtherRR MEDICARE GROUP
IL466637OtherHEALTHLINK
IL038009435Medicaid
ILP00287309OtherRR MEDICARE