Basic Information
| Provider Information | |||||||||
| NPI: | 1568572402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2428 KNOB CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232825054 | ||||||||
| FaxNumber: | 4232820981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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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 | 207R00000X | 2002017394 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 2002017394 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 45843 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 205889413 | 05 | MO | MEDICAID |