Basic Information
| Provider Information | |||||||||
| NPI: | 1235239906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINK | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627032403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627023749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
| FaxNumber: | 2175272830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2006 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036098756 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036098756 | 05 | IL | MEDICAID |