Healthcare Provider Details

I. General information

NPI: 1336146703
Provider Name (Legal Business Name): SCOTT J FILLMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2203
  • Fax: 701-234-2899
Mailing address:
  • Phone: 701-234-2203
  • Fax: 701-234-2899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberH9633
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5962
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: