Healthcare Provider Details

I. General information

NPI: 1154669257
Provider Name (Legal Business Name): SCOTT MICHAEL DEDOE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE EMERGENCY MEDICINE DEPARTMENT
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

1221 PINE GROVE AVE EMERGENCY MEDICINE DEPARTMENT
PORT HURON MI
48060-3511
US

V. Phone/Fax

Practice location:
  • Phone: 810-989-3300
  • Fax: 810-985-2671
Mailing address:
  • Phone: 810-989-3300
  • Fax: 810-985-2671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006596
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: