Basic Information
| Provider Information | |||||||||
| NPI: | 1992884456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GLENN | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 HOSPITAL DR | ||||||||
| Address2: | P.O. BOX 905 | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 INDUSTRIAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | LYNDON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489501 | ||||||||
| FaxNumber: | 8027483420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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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 | 207Q00000X | MA72009 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 042-0011945 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8975604 | 05 | NJ | MEDICAID | 3075635 | 05 | NH | MEDICAID | 1017399 | 05 | VT | MEDICAID |