Provider Demographics
NPI:1043284144
Name:MERCOLA, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:MERCOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7420 CENTRAL AVE
Mailing Address - Street 2:SUITE 2040
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:708-776-7220
Mailing Address - Fax:708-776-7226
Practice Address - Street 1:7420 CENTRAL AVE
Practice Address - Street 2:SUITE 2040
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305
Practice Address - Country:US
Practice Address - Phone:708-776-7220
Practice Address - Fax:708-776-7226
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2023-03-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036084477208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36084477Medicaid
IL36084477Medicaid