Healthcare Provider Details

I. General information

NPI: 1427805258
Provider Name (Legal Business Name): SPENCER PHILIP SHOLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 5000
O FALLON IL
62269-1282
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 5000
O FALLON IL
62269-1282
US

V. Phone/Fax

Practice location:
  • Phone: 618-641-5803
  • Fax: 618-607-5116
Mailing address:
  • Phone: 618-641-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: