Provider Demographics
NPI:1275647646
Name:SCOTT, KENNETH G (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:SCOTT
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 58
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0058
Mailing Address - Country:US
Mailing Address - Phone:866-942-0799
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:2451 INTELLIPLEX DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8580
Practice Address - Country:US
Practice Address - Phone:317-392-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010494162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200386650AMedicaid
H73458Medicare UPIN
IN200386650AMedicaid