Basic Information
| Provider Information | |||||||||
| NPI: | 1770691503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PYNNONEN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065246218 | ||||||||
| Practice Location | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065246218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301046352 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00186817 | 01 | RAILROAD MEDICARE | OTHER | 010Z76002 SP046352 | 01 | MI | BLUE CROSS ER SERVICES | OTHER | 080Z710040 SP046352 | 01 | MI | BLUE CROSS-OFFICE | OTHER | 4627462 | 05 | MI | MEDICAID | 238646 | 01 | MI | RHC MEDICARE | OTHER | 2765011 | 05 | MI | MEDICAID |