1194768655 NPI number — MR. CARL BRENT SCOTT PT

Table of content: (NPI 1972656528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194768655 NPI number — MR. CARL BRENT SCOTT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
CARL
Provider Middle Name:
BRENT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194768655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 PINEHURST CT.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GIBSON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-478-8249
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 MAHANEY AVE., STE. 6
Provider Second Line Business Practice Location Address:
NORTHEASTERN PHYSICAL REHAB
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-458-5115
Provider Business Practice Location Address Fax Number:
918-458-5119
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1994 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 650020254 . This is a "RR MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100834890A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: A002 . This is a "TRICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 175254900 . This is a "DEPT OF LABOR" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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