Provider Demographics
NPI:1073796868
Name:SCOTT J. MISCOVICH MD, LLC
Entity Type:Organization
Organization Name:SCOTT J. MISCOVICH MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MISCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-247-7596
Mailing Address - Street 1:45-1144 KAMEHAMEHA HWY
Mailing Address - Street 2:#500
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3244
Mailing Address - Country:US
Mailing Address - Phone:808-247-7596
Mailing Address - Fax:808-247-7053
Practice Address - Street 1:45-1144 KAMEHAMEHA HWY
Practice Address - Street 2:#500
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3244
Practice Address - Country:US
Practice Address - Phone:808-247-7596
Practice Address - Fax:808-247-7053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD6854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05672605Medicaid
HIT065197OtherHMSA
HIT065197OtherHMSA
HI05672605Medicaid