Provider Demographics
NPI:1114188950
Name:SHOLEM, SCOTT
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:SHOLEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 40TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3356
Mailing Address - Country:US
Mailing Address - Phone:602-996-4747
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3356
Practice Address - Country:US
Practice Address - Phone:602-996-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 390200000X
AZ0084702086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007970Medicaid