Provider Demographics
NPI:1235160888
Name:MAYNARD, SCOTT E (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 535744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-5510
Mailing Address - Country:US
Mailing Address - Phone:844-294-5114
Mailing Address - Fax:865-691-0843
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 5-B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-3460
Practice Address - Fax:423-224-3465
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND16269207L00000X
TN40808207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010343488Medicaid
TN3820575Medicaid
4127819OtherBCBST
P00337665OtherRAILROAD MEDICARE
TN3820575Medicare PIN
TN3820575Medicaid