Basic Information
| Provider Information | |||||||||
| NPI: | 1093702508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 AZALEA CT | ||||||||
| Address2: | STE C | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436920570 | ||||||||
| FaxNumber: | 8434979566 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 AZALEA CT | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436920570 | ||||||||
| FaxNumber: | 8434979566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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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 | 2085R0202X | 18517 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 154758900 | 01 | SC | FEDERAL BLACK LUNG | OTHER | B9734 | 01 | SC | MEDCOST | OTHER | 89066EJ | 05 | NC | MEDICAID | 570525838 | 01 | SC | STANDARD TAX ID | OTHER | 185178 | 05 | SC | MEDICAID | 066EJ | 01 | NC | BCBS OF NORTH CAROLINA | OTHER | 154758900 | 01 | SC | US DEPT OF LABOR | OTHER |