Basic Information
Provider Information | |||||||||
NPI: | 1194768655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCOTT | ||||||||
FirstName: | CARL | ||||||||
MiddleName: | BRENT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1212 PINEHURST CT. | ||||||||
Address2: |   | ||||||||
City: | FORT GIBSON | ||||||||
State: | OK | ||||||||
PostalCode: | 74434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184788249 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2021 MAHANEY AVE., STE. 6 | ||||||||
Address2: | NORTHEASTERN PHYSICAL REHAB | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 74464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184585115 | ||||||||
FaxNumber: | 9184585119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 12/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1994 | OK | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 650020254 | 01 | OK | RR MEDICARE | OTHER | 100834890A | 05 | OK |   | MEDICAID | A002 | 01 | OK | TRICARE | OTHER | 175254900 | 01 | OK | DEPT OF LABOR | OTHER |