Provider Demographics
NPI:1043767296
Name:ANDERSON, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 S SAINT JOSEPH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:WI
Mailing Address - Zip Code:54612-1401
Mailing Address - Country:US
Mailing Address - Phone:608-323-9998
Mailing Address - Fax:608-323-2150
Practice Address - Street 1:464 S SAINT JOSEPH AVE STE 100
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1401
Practice Address - Country:US
Practice Address - Phone:608-323-9998
Practice Address - Fax:608-323-2150
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2343-19208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation