Basic Information
| Provider Information | |||||||||
| NPI: | 1740380765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERUBE | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 WATSON RD | ||||||||
| Address2: | |||||||||
| City: | OWINGS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207369720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018558526 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 HOSPITAL RD | ||||||||
| Address2: | ATTN: CHRISTINE THORNE | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 174400000X | 03924 | MD | Y | Other Service Providers | Specialist |
No ID Information.