Provider Demographics
NPI:1184656233
Name:SCOTT, GLEN R JR (DO)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:R
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:2720 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4810
Mailing Address - Country:US
Mailing Address - Phone:803-791-2000
Mailing Address - Fax:864-366-9012
Practice Address - Street 1:146 E HOSPITAL DR STE 120A
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-936-7076
Practice Address - Fax:803-936-7925
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-01-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC0590207T00000X
SC5902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0590Medicaid
SC3255Medicare PIN
SC2083Medicare PIN
H14210Medicare UPIN