Provider Demographics
NPI:1518269539
Name:DAVIS, SCOTT J (NP-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1397
Mailing Address - Country:US
Mailing Address - Phone:815-786-7150
Mailing Address - Fax:815-786-3785
Practice Address - Street 1:1310 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1397
Practice Address - Country:US
Practice Address - Phone:815-786-7150
Practice Address - Fax:815-786-3785
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008413363LF0000X
IL209008413363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6309OtherMEDICARE GROUP
ILF400101031OtherMEDICARE INDIVIDUAL