Provider Demographics
NPI:1093783334
Name:SILLIMAN, SCOTT LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LEE
Last Name:SILLIMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:UFJP NEUROLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-3960
Practice Address - Fax:904-244-9493
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME728142084N0400X, 207R00000X
GA0440992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000758502BMedicaid
FL3794407-00Medicaid
GA000758502AMedicaid
FL3794407-00Medicaid
GA000758502BMedicaid
FL28553YMedicare PIN
GAP00715975Medicare PIN
FL130013634Medicare PIN