=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720005655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT DAVID WAUGH PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 BEACON ST
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-5587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-232-6633
-----------------------------------------------------
Fax | 617-232-6832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 DAMON RD
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02339-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-871-6659
-----------------------------------------------------
Fax | 617-232-6832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 8158
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 8158
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | MA
-----------------------------------------------------
Identifier Issuer | MA PT LISENCE NUMBER
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 8158
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | MA
-----------------------------------------------------
Identifier Issuer | MA PT LISENCE NUMBER
-----------------------------------------------------