Provider Demographics
NPI:1528199973
Name:SHROYER, CASEY D (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:D
Last Name:SHROYER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:810 W. ANTHONY DRIVE
Practice Address - Street 2:ORTHOPEDICS
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-383-2255
Practice Address - Fax:217-326-0210
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19401Medicare UPIN
ILK08121Medicare ID - Type Unspecified
IL6447860015Medicare NSC
IL0533210001Medicare NSC
ILQ19401Medicare UPIN
ILIL3270434Medicare PIN