Basic Information
| Provider Information | |||||||||
| NPI: | 1548259971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | DEMOND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT | ||||||||
| OtherFirstName: | EDWARD | ||||||||
| OtherMiddleName: | DEMOND | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | III | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 933132 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 143 GOUGLER AVE | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442402401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731016 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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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 | 207Q00000X | 35-085181 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2557700 | 05 | OH | MEDICAID | 4156762 | 01 | OH | MEDICARE ID | OTHER |