Healthcare Provider Details

I. General information

NPI: 1629814348
Provider Name (Legal Business Name): JACOB BAYLEY SHOLL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3030
  • Fax:
Mailing address:
  • Phone: 217-788-3156
  • Fax: 217-788-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: