Healthcare Provider Details

I. General information

NPI: 1750748257
Provider Name (Legal Business Name): MATTHEW THOMAS SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 07/11/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88TH MEDICAL GROUP 4881 SUGAR MAPLE DR.
WPAFB OH
45433
US

IV. Provider business mailing address

88TH MEDICAL GROUP 4881 SUGAR MAPLE DR.
WPAFB OH
45433
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-8718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR4633
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberR4633
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: