Healthcare Provider Details

I. General information

NPI: 1962419747
Provider Name (Legal Business Name): SCOTT DAVID MINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 270-461-5008
  • Fax: 931-645-4104
Mailing address:
  • Phone: 270-431-4677
  • Fax: 931-645-4104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58272
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: