1063475309 NPI number — CHARLOTTE SCOTT PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063475309 NPI number — CHARLOTTE SCOTT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
CHARLOTTE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1063475309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4204 E STAN SCHLUETER LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76542-8352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-690-2800
Provider Business Mailing Address Fax Number:
254-690-5401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 2245, 58TH STREET AND 761ST TANK BATTALION AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-287-5029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2006

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: 363A00000X , with the licence number:  PA01636 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00269379 . This is a "RR/MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8N9121 . This is a "BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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