Basic Information
| Provider Information | |||||||||
| NPI: | 1861420010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LYNN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HORWOOD PLACE | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153949462 | ||||||||
| FaxNumber: | 3157135291 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HORWOOD PLACE | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153949462 | ||||||||
| FaxNumber: | 3157135291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 198700-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01650971 | 05 | NY | MEDICAID |