Provider Demographics
NPI:1093705030
Name:HIATT, SCOTT R (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:HIATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-463-5050
Mailing Address - Fax:208-463-5040
Practice Address - Street 1:1524 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6008
Practice Address - Country:US
Practice Address - Phone:208-463-5050
Practice Address - Fax:208-463-5040
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO289208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149338OtherBLUE SHIELD
IDS5486OtherBLUE CROSS
ID806467500Medicaid
G17120Medicare UPIN
ID806467500Medicaid
ID1302690Medicare PIN