Healthcare Provider Details

I. General information

NPI: 1548795222
Provider Name (Legal Business Name): SPENCER EVAN THREW D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HEATHER DR
MAHOMET IL
61853-2754
US

IV. Provider business mailing address

306 BERINGER CIR
URBANA IL
61802-2276
US

V. Phone/Fax

Practice location:
  • Phone: 217-586-8400
  • Fax:
Mailing address:
  • Phone: 727-322-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036178174
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036178174
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: