Healthcare Provider Details

I. General information

NPI: 1275535551
Provider Name (Legal Business Name): MICHAEL SHANE SCOTT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SHANE SCOTT

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 FAIRFIELD DR
NEW ALBANY MS
38652-3107
US

IV. Provider business mailing address

118 FAIRFIELD DR
NEW ALBANY MS
38652-3107
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-0898
  • Fax: 662-534-8905
Mailing address:
  • Phone: 662-534-0898
  • Fax: 662-534-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17807
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17807
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: