Basic Information
| Provider Information | |||||||||
| NPI: | 1053390237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCHILL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 SHILOH STATION RD | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622694000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186247383 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 N 7 HILLS RD | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622694111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186246181 | ||||||||
| FaxNumber: | 6186247172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002702 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.