Basic Information
| Provider Information | |||||||||
| NPI: | 1417926791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORKELL | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94580 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981246880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525428553 | ||||||||
| FaxNumber: | 9525136880 | ||||||||
| Practice Location | |||||||||
| Address1: | 6808 220TH ST SW | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980432122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257447420 | ||||||||
| FaxNumber: | 4256703378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD00016032 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8600413 | 05 | WA | MEDICAID |