=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700297520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTIVE HEALTH PARTNERS IL S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2014
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E SCRANTON AVE STE 303
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-816-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E. SCRANTON AVENUE SUITE 303
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-816-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SCOTT MACKAY MORCOTT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-757-8686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 36099609
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------