Healthcare Provider Details

I. General information

NPI: 1760480974
Provider Name (Legal Business Name): SCOTT WILLIAM EATHORNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30055 NORTHWESTERN HWY #30
FARMINGTON HILLS MI
48334-3230
US

IV. Provider business mailing address

15990 W 9 MILE RD
SOUTHFIELD MI
48075-4826
US

V. Phone/Fax

Practice location:
  • Phone: 248-865-4030
  • Fax: 248-426-7335
Mailing address:
  • Phone: 248-849-4226
  • Fax: 248-849-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301055302
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301056302
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: