Healthcare Provider Details

I. General information

NPI: 1184656233
Provider Name (Legal Business Name): GLEN R SCOTT JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 E HOSPITAL DR STE 120A
WEST COLUMBIA SC
29169-4800
US

IV. Provider business mailing address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7076
  • Fax: 803-936-7925
Mailing address:
  • Phone: 803-791-2000
  • Fax: 864-366-9012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number0590
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number590
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: