Healthcare Provider Details

I. General information

NPI: 1053390237
Provider Name (Legal Business Name): GREGORY SCOTT CHURCHILL PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N 7 HILLS RD
O FALLON IL
62269-4111
US

IV. Provider business mailing address

409 SHILOH STATION RD
O FALLON IL
62269-4000
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-6181
  • Fax: 618-624-7172
Mailing address:
  • Phone: 618-624-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002702
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: