Healthcare Provider Details

I. General information

NPI: 1720541527
Provider Name (Legal Business Name): NELSON EUGENE SHREVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

IV. Provider business mailing address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-5480
  • Fax: 618-222-4792
Mailing address:
  • Phone: 618-233-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021030583
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036165768
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036165768
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: