Provider Demographics
NPI:1932671625
Name:PINA, MATT CHRISTOPHER
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:CHRISTOPHER
Last Name:PINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 JONES ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1430
Mailing Address - Country:US
Mailing Address - Phone:618-435-1948
Mailing Address - Fax:
Practice Address - Street 1:2027 CASEY AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4477
Practice Address - Country:US
Practice Address - Phone:740-770-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILP500-5439-2244172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP500-5439-2244Medicaid