Provider Demographics
NPI:1083699524
Name:SCOTT, KENNETH L (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 DESALES AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1161
Mailing Address - Country:US
Mailing Address - Phone:423-495-2620
Mailing Address - Fax:423-495-7887
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-495-2620
Practice Address - Fax:423-495-7887
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN850207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056002413AMedicaid
GA056002413AMedicaid
TN3710153Medicare PIN