Provider Demographics
NPI:1124028469
Name:SCOTT, MARK J (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:SCOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7945 WOLF RIVER BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1762
Mailing Address - Country:US
Mailing Address - Phone:901-684-2400
Mailing Address - Fax:901-722-0442
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:STE 300
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-684-2400
Practice Address - Fax:901-722-0442
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0004207RH0003X
ARPA174207RH0003X
MS06PA022207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3668933Medicaid
AR1124028469OtherBCBS AR
AR1124028469OtherBCBS AR
TN3668933Medicaid
TN36689331Medicare PIN