Healthcare Provider Details

I. General information

NPI: 1184842601
Provider Name (Legal Business Name): KEVIN CHARLES SCOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W CHELTENHAM AVE
WYNCOTE PA
19095-2946
US

IV. Provider business mailing address

2401 W CHELTENHAM AVE
WYNCOTE PA
19095-2946
US

V. Phone/Fax

Practice location:
  • Phone: 215-444-7471
  • Fax: 215-695-2935
Mailing address:
  • Phone: 215-444-7471
  • Fax: 215-695-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT-188510
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-436388
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0201073
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier1023180950001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: