Basic Information
| Provider Information | |||||||||
| NPI: | 1881914513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLETIER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1638 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122011638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077774111 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 CAMPUS AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042406030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778120 | ||||||||
| FaxNumber: | 2077778984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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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 | MD19522 | ME | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.