Basic Information
| Provider Information | |||||||||
| NPI: | 1760461800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173329093 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 S ADAMS ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173325099 | ||||||||
| FaxNumber: | 8173329093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L7372 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | L7372 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | L7372 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 166774310 | 05 | TX | MEDICAID | P00660206 | 01 | RAILROAD MEDICARE | OTHER | 0057MP | 01 | TX | BCBS | OTHER | 166774304 | 05 | TX | MEDICAID |