Provider Demographics
NPI:1033196126
Name:THOMAS, SCOTT G (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:G
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:SUITE 502
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1075
Practice Address - Country:US
Practice Address - Phone:574-647-5875
Practice Address - Fax:574-647-5878
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037023A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100338820Medicaid
IN000000901457OtherANTHEM BCBS
IN000000901457OtherANTHEM BCBS
IN100338820Medicaid