=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699732214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT ORTHOPEDIC CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 1ST AVE SUITE 400
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25702-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-525-6905
-----------------------------------------------------
Fax | 304-525-4316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4100
-----------------------------------------------------
City | BARBOURSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25504-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-955-6200
-----------------------------------------------------
Fax | 304-399-2526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | LUIS BOLANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-525-6905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------