Provider Demographics
NPI:1124042197
Name:PETTY, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:PETTY
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 678948
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8948
Mailing Address - Country:US
Mailing Address - Phone:828-213-0895
Mailing Address - Fax:828-213-0590
Practice Address - Street 1:534 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4610
Practice Address - Country:US
Practice Address - Phone:828-213-0895
Practice Address - Fax:828-213-0590
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7815A2085R0202X
NC387232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967251Medicaid
WYW21689Medicare PIN
NCF28422Medicare UPIN