Basic Information
| Provider Information | |||||||||
| NPI: | 1699729434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGNER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 945 BETHESDA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1246 ASHLAND AVE STE 205 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404545271 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 35-095771 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0000X | 35-095771 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | D0045813 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0000X | D0045813 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207R00000X | D0045813 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 904001300 | 05 | MD | MEDICAID | 3066953 | 05 | OH | MEDICAID | 61131403S108NE | 01 | MD | BLUE SHIELD | OTHER | 930065996 | 01 | MD | RAILROAD | OTHER |