Basic Information
| Provider Information | |||||||||
| NPI: | 1578598850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | MCKENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHYSICIANS ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH STREET PH 1-137 | ||||||||
| Address2: | ASSOCIATES IN EMERGENCY SERVICES CLINIC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W 168TH STREET PH 1-137 | ||||||||
| Address2: | COLUMBIA UNIVERSITY MED CENTER | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/19/2006 | ||||||||
| NPIReactivationDate: | 11/16/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006243 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 01903075 | 05 | NY | MEDICAID |