Healthcare Provider Details

I. General information

NPI: 1114996204
Provider Name (Legal Business Name): SCOTT K SCHONEWOLF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST SUITE 200
CARBONDALE IL
62901
US

IV. Provider business mailing address

300 W OAK ST
CARBONDALE IL
62901-1400
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3777
  • Fax: 618-453-1102
Mailing address:
  • Phone: 618-536-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036-114842
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-114842
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: