Healthcare Provider Details

I. General information

NPI: 1073513313
Provider Name (Legal Business Name): STANTON G SCHULTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 NORTH 12TH STREET SOUTHERN ILLINOIS CONSULTANTS FOR KIDNEY DISEASE, S.C.
MT. VERNON IL
62864-4314
US

IV. Provider business mailing address

P.O. BOX 1704 416 NORTH 12TH STREET
MT. VERNON IL
62864-0034
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-4850
  • Fax: 618-244-7985
Mailing address:
  • Phone: 618-244-4850
  • Fax: 618-244-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number1027161
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: