Healthcare Provider Details

I. General information

NPI: 1033386115
Provider Name (Legal Business Name): MICHAEL LEROY MATTESON PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST SUITE 105
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

PO BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-536-2565
  • Fax: 618-536-2835
Mailing address:
  • Phone: 618-457-5200
  • Fax: 618-351-4821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110003884
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number385000710
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: