Basic Information
| Provider Information | |||||||||
| NPI: | 1073086252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRHURST | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178658133 | ||||||||
| FaxNumber: | 3178598239 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199322300 | ||||||||
| FaxNumber: | 2198522502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2019 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71008681A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.