Healthcare Provider Details

I. General information

NPI: 1053001057
Provider Name (Legal Business Name): EVAN MERRICK SEMBELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 03/17/2024
Certification Date: 03/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S. GRAND, M260
ST. LOUIS MO
63104
US

IV. Provider business mailing address

816 E LAKE SHORE DR
SPRINGFIELD IL
62712-8966
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2919
  • Fax:
Mailing address:
  • Phone: 217-725-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: