Healthcare Provider Details

I. General information

NPI: 1932541927
Provider Name (Legal Business Name): MUTHANA SARTAWI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 FOX DR
CHAMPAIGN IL
61820-7553
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1237
  • Fax: 217-366-6106
Mailing address:
  • Phone: 217-366-8107
  • Fax: 217-366-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number036.132057
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036.132057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: