Basic Information
| Provider Information | |||||||||
| NPI: | 1992200331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795737905 | ||||||||
| FaxNumber: | 4795737906 | ||||||||
| Practice Location | |||||||||
| Address1: | 5428 ELLSWORTH RD STE B | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795737905 | ||||||||
| FaxNumber: | 4795737906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 279 | AR | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.