Provider Demographics
NPI:1104836113
Name:WESLOW, SCOTT T (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:WESLOW
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 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-965-4055
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:STE 310
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8300
Practice Address - Fax:920-288-8305
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49538208M00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104836113Medicaid
WI1104836113Medicaid
WI1104836113Medicaid