Provider Demographics
NPI:1114115433
Name:SCOTT EYE CLINIC PA
Entity Type:Organization
Organization Name:SCOTT EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-968-3937
Mailing Address - Street 1:214 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-5134
Mailing Address - Country:US
Mailing Address - Phone:479-968-3937
Mailing Address - Fax:479-967-6731
Practice Address - Street 1:214 E 4TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5134
Practice Address - Country:US
Practice Address - Phone:479-968-3937
Practice Address - Fax:479-967-6731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148782722Medicaid
AR1114115433OtherMEDICARE NSC
AR146049722Medicaid
AR148782722Medicaid
48954Medicare PIN