Basic Information
Provider Information | |||||||||
NPI: | 1205826971 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | SCOTT | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 6TH AVE N | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202525131 | ||||||||
FaxNumber: | 3202402118 | ||||||||
Practice Location | |||||||||
Address1: | 1200 6TH AVE N | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202525131 | ||||||||
FaxNumber: | 3202402118 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 29998 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 986006 | 01 |   | PREFERRED ONE | OTHER | 0423574 | 01 |   | MEDICA HEALTH PLANS | OTHER | 2114120 | 01 |   | FIRST HEALTH PLAN | OTHER | HP22743 | 01 |   | HEALTH PARTNERS | OTHER | 600908 | 01 |   | ARAZ GROUP AMERICAS PPO | OTHER | 6D061DA | 01 |   | BCBS | OTHER | 220896 | 01 |   | U CARE | OTHER |