Provider Demographics
NPI:1275535551
Name:SCOTT, MICHAEL SHANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:118 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652
Mailing Address - Country:US
Mailing Address - Phone:662-534-0898
Mailing Address - Fax:662-534-8905
Practice Address - Street 1:118 FAIRFIELD DR
Practice Address - Street 2:INTERNAL MEDICINE AND PEDIATRIC CLINIC OF NEW ALBANY
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652
Practice Address - Country:US
Practice Address - Phone:662-534-0898
Practice Address - Fax:662-534-8905
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17807208000000X, 207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS100147271Medicaid
MS020700026OtherTAX ID
MS020700026OtherTAX ID
MSH55292Medicare UPIN