Basic Information
| Provider Information | |||||||||
| NPI: | 1023082559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | ATTN SURGICAL SERVICES | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103424917 | ||||||||
| FaxNumber: | 8103421335 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | ATTN SURGICAL SERVICES | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103424917 | ||||||||
| FaxNumber: | 8103421335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704196231 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P000005361 | 01 | MI | TRAVELER'S | OTHER | 4444570 | 05 | MI | MEDICAID | BS196231 | 01 | MI | BLUE SHIELD | OTHER |