Healthcare Provider Details

I. General information

NPI: 1144803396
Provider Name (Legal Business Name): SCOTT AUSTIN SCHLAGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 N KEDZIE BLVD
CHICAGO IL
60647-2603
US

IV. Provider business mailing address

1096 SEVILLE RD
ROCHESTER HILLS MI
48309-3025
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-2700
  • Fax:
Mailing address:
  • Phone: 248-917-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003574A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: