Basic Information
| Provider Information | |||||||||
| NPI: | 1770578817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3640 NEW VISION DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604824440 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 RANDALLIA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603734000 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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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 | 207P00000X | 01047183A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104874660 | 05 | MI | MEDICAID | 000000024482 | 01 | MPLAN | OTHER | 200345880 | 05 | IN | MEDICAID | 000000212873 | 01 | IN | ANTHEM | OTHER | 2518618 | 05 | OH | MEDICAID |