=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063415362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT L TUCKER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 10/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1345A WESTGATE CENTER DR
-----------------------------------------------------
City | WINSTON-SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-8483
-----------------------------------------------------
Fax | 336-768-1195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1345 WESTGATE CENTER DR STE A
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-3041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-8483
-----------------------------------------------------
Fax | 336-768-1195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 200001832740
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------