Provider Demographics
NPI:1174636278
Name:SCIDMORE, NOEL C (MD)
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:C
Last Name:SCIDMORE
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 3160
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0160
Mailing Address - Country:US
Mailing Address - Phone:706-858-2873
Mailing Address - Fax:
Practice Address - Street 1:4750 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-5164
Practice Address - Country:US
Practice Address - Phone:706-858-2873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0526302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3871497Medicare ID - Type Unspecified
GA92BBFZDMedicare ID - Type Unspecified
F16268Medicare UPIN