Basic Information
| Provider Information | |||||||||
| NPI: | 1285005405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT ORTHOPEDIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045256154 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045256154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | PROCTOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3045256905 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 352265 | 05 | OH | MEDICAID | 0010681000 | 05 | WV | MEDICAID |