MEDICARE: KEITH WESLEY SCOTT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	027188	CT

General Provider Information

NPI Number	:	1114172566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH WESLEY SCOTT MD

Provider Business Mailing Address
First Line	:	1349 ALTOONA PILLAR ROCK RD
Second Line	:
City	:	ROSBURG
State	:	WA
Zip	:	98643-9614
Country	:	US
Telephone Number	:	860-508-3109
Fax Number	:

Provider Business Practice Location Address
First Line	:	1349 ALTOONA PILLAR ROCK RD
Second Line	:
City	:	ROSBURG
State	:	WA
Zip	:	98643-9614
Country	:	US
Telephone Number	:	860-508-3109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2008
Last Update Date	:	11/27/2008

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