Healthcare Provider Details

I. General information

NPI: 1194768655
Provider Name (Legal Business Name): CARL BRENT SCOTT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 MAHANEY AVE., STE. 6 NORTHEASTERN PHYSICAL REHAB
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1212 PINEHURST CT.
FORT GIBSON OK
74434
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-5115
  • Fax: 918-458-5119
Mailing address:
  • Phone: 918-478-8249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1994
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier650020254
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerRR MEDICARE
# 2
Identifier100834890A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 3
IdentifierA002
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerTRICARE
# 4
Identifier175254900
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerDEPT OF LABOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: