Healthcare Provider Details

I. General information

NPI: 1750545463
Provider Name (Legal Business Name): SCOTT TYSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 HWY 36 W STE. 100
ROSEVILLE MN
55113
US

IV. Provider business mailing address

2355 HWY 36 W STE. 100
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-2000
  • Fax:
Mailing address:
  • Phone: 651-292-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57928
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.121447
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number15031-320
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number47633
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24302
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: