=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659344554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH A SCOTT D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12150 30 MILE RD STE 105
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48095-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-336-7333
-----------------------------------------------------
Fax | 586-336-7332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12150 30 MILE RD STE 105
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48095-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-336-7333
-----------------------------------------------------
Fax | 586-336-7332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | KS013195
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 5101013195
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------