Provider Demographics
NPI:1639367535
Name:MCPHERSON, MATTHEW (RD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCPHERSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 LYNN ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2262
Mailing Address - Country:US
Mailing Address - Phone:618-698-9114
Mailing Address - Fax:
Practice Address - Street 1:20733 N. BROAD ST.
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1499
Practice Address - Country:US
Practice Address - Phone:217-854-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003834133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered