Healthcare Provider Details

I. General information

NPI: 1053635870
Provider Name (Legal Business Name): SCOTT SPORTS MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6918 GUNN HWY STE C
TAMPA FL
33625-3800
US

IV. Provider business mailing address

6918 GUNN HWY STE C
TAMPA FL
33625-3800
US

V. Phone/Fax

Practice location:
  • Phone: 813-855-8450
  • Fax: 813-855-7540
Mailing address:
  • Phone: 813-855-8450
  • Fax: 813-855-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME100433
License Number StateFL

VIII. Authorized Official

Name: DR. KEVIN LAMONT SCOTT
Title or Position: OWNER
Credential: M.D.
Phone: 813-855-8450