Healthcare Provider Details

I. General information

NPI: 1114188950
Provider Name (Legal Business Name): MR. SCOTT SHOLEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

IV. Provider business mailing address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

V. Phone/Fax

Practice location:
  • Phone: 602-996-4747
  • Fax:
Mailing address:
  • Phone: 602-996-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number008470
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number008470
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: