Healthcare Provider Details

I. General information

NPI: 1295260032
Provider Name (Legal Business Name): MATTIE ARSENEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2017
Last Update Date: 11/08/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 FIELDS SOUTH DR
CHAMPAIGN IL
61822-3743
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPG183132
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036171507
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: