Provider Demographics
NPI:1205015278
Name:SCARLETT, KERMITH (DO)
Entity Type:Individual
Prefix:
First Name:KERMITH
Middle Name:
Last Name:SCARLETT
Suffix:
Gender:M
Credentials:DO
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 23068
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-3068
Mailing Address - Country:US
Mailing Address - Phone:517-267-1270
Mailing Address - Fax:517-267-1272
Practice Address - Street 1:1808 S PENNSYLVANIA AVE
Practice Address - Street 2:STE A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1897
Practice Address - Country:US
Practice Address - Phone:517-268-6608
Practice Address - Fax:517-268-6609
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKS009329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3105211Medicaid
MIKS009329OtherLIC #
MI0153303015OtherBCBS
MI3105211Medicaid
MI383163712OtherEIN
MIKS009329OtherLIC #