Healthcare Provider Details

I. General information

NPI: 1891796835
Provider Name (Legal Business Name): PATRICK L MOLT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 NW 10TH ST
FAIRFIELD IL
62837-1237
US

IV. Provider business mailing address

PO BOX 465
FAIRFIELD IL
62837-0465
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-3813
  • Fax: 618-842-2514
Mailing address:
  • Phone: 618-842-3813
  • Fax: 618-842-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-100313
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: