1629094982 NPI number — DR. MATTIE MARY SANDRA SCOTT M.D.

Table of content: DR. MATTIE MARY SANDRA SCOTT M.D. (NPI 1629094982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629094982 NPI number — DR. MATTIE MARY SANDRA SCOTT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
MATTIE
Provider Middle Name:
MARY SANDRA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1629094982
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8423 HOLLY RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-2488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-694-7095
Provider Business Mailing Address Fax Number:
810-694-7224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8423 HOLLY RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-2488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-694-7095
Provider Business Practice Location Address Fax Number:
810-694-7224
Provider Enumeration Date:
07/13/2006

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: 207VX0000X , with the licence number:  4301075129 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 4301075129 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0986090 . This is a "HEALTH PLUS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4123288 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972715977 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10111740001 . This is a "THE WELLNESS PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 19727715977 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2076271 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 099270 . This is a "TOTAL HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C6735 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1692504601 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P104137 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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