Basic Information
| Provider Information | |||||||||
| NPI: | 1750386199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6227 FRANKFORT HWY | ||||||||
| Address2: | |||||||||
| City: | BENZONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496168632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318829661 | ||||||||
| FaxNumber: | 2318829616 | ||||||||
| Practice Location | |||||||||
| Address1: | 2198 US 31 S | ||||||||
| Address2: | |||||||||
| City: | MANISTEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317233567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SC008093 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3015713 | 05 | MI | MEDICAID |