Basic Information
| Provider Information | |||||||||
| NPI: | 1346246501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083818866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 N 1ST ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837026132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083819384 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 01030263 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | M-16869 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 100358340 | 05 | IN | MEDICAID |