Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036-114842 | IL |
N | 207QS0010X | Family Doctor - Sports Medicine | 036-114842 | IL |
NPI | 1114996204 |
---|---|
Provider Name | Scott K Schonewolf |
First Address | Carbondale, IL 62901-1400 |
Second Address | Carbondale, IL 62901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 09/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036114842 | (05) | IL |
I14361 | (02) |