Basic Information
| Provider Information | |||||||||
| NPI: | 1760480974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EATHORNE | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15990 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488494226 | ||||||||
| FaxNumber: | 2488494240 | ||||||||
| Practice Location | |||||||||
| Address1: | 30055 NORTHWESTERN HWY | ||||||||
| Address2: | #30 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488654030 | ||||||||
| FaxNumber: | 2484267335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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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 | 207QS0010X | 4301055302 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 4301056302 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 297537810 | 05 | MI | MEDICAID |