Healthcare Provider Details

I. General information

NPI: 1053460691
Provider Name (Legal Business Name): SCOTT R SHORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 EXECUTIVE PKWY SUITE 230
TOLEDO OH
43606-1326
US

IV. Provider business mailing address

P O BOX 74872
CLEVELAND OH
44194-4872
US

V. Phone/Fax

Practice location:
  • Phone: 419-531-3500
  • Fax: 419-531-1877
Mailing address:
  • Phone: 419-531-3500
  • Fax: 419-531-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35-07-8534 S
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number35-07-8534 S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: