Provider Demographics
NPI:1134185945
Name:STILLWELL, SCOTT M (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:STILLWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HERITAGE RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4017
Mailing Address - Country:US
Mailing Address - Phone:920-605-3115
Mailing Address - Fax:920-486-6826
Practice Address - Street 1:1500 HERITAGE RD STE A
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4017
Practice Address - Country:US
Practice Address - Phone:920-605-3115
Practice Address - Fax:920-486-6826
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27813207Q00000X
WI27813-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31379700Medicaid
WI001060080Medicare ID - Type Unspecified
WI31379700Medicaid