Healthcare Provider Details

I. General information

NPI: 1891560918
Provider Name (Legal Business Name): SHILLMED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 E MISSION AVE STE 102
SPOKANE VALLEY WA
99216-3101
US

IV. Provider business mailing address

17405 E 15TH AVE
SPOKANE VALLEY WA
99016-5431
US

V. Phone/Fax

Practice location:
  • Phone: 347-688-6484
  • Fax: 888-861-1458
Mailing address:
  • Phone: 480-765-7298
  • Fax: 888-861-1458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OTTO SHILL
Title or Position: OWNER
Credential: DO
Phone: 347-688-6484