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NPI Code Detail

MEDICARE: SCOTT STREET MEDICAL GROUP LLC

MEDICARE: SCOTT STREET MEDICAL GROUP LLC
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
1207QG0300XGeriatric Medicine (Family Medicine) Physician
2207R00000XInternal Medicine Physician
3363LF0000XFamily Nurse Practitioner
4207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1669085544
Entity Type Code : Organization
Provider Name (Legal Business Name) : SCOTT STREET MEDICAL GROUP LLC
Provider Business Mailing Address
First Line : 500 SCOTT ST
Second Line :
City : WILKES BARRE
State : PA
Zip : 18702-5616
Country : US
Telephone Number : 570-824-1700
Fax Number : 570-270-9060
Provider Business Practice Location Address
First Line : 500 SCOTT ST
Second Line :
City : WILKES BARRE
State : PA
Zip : 18702-5616
Country : US
Telephone Number : 570-824-1700
Fax Number : 570-270-9060
Authorized Official
Title or Position : CREDENTIALING
Name : ELIZABETH WAYMIRE
Credential : CPC
Telephone Number : 570-693-6163
Provider Enumeration Date : 08/28/2020
Last Update Date : 08/28/2020

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Directions to “SCOTT STREET MEDICAL GROUP LLC ” Practice Location

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