Provider Demographics
NPI:1346359841
Name:SHEPARD, SCOTT R (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:SHEPARD
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:STE R.705
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-7200
Mailing Address - Fax:215-707-3831
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:SUITE 724
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-7200
Practice Address - Fax:215-707-3831
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA067529207T00000X
TXN0457207T00000X
PAMD459537207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S5475OtherBCBSTX
NJ7624107Medicaid
TX196101301Medicaid
TX196101301Medicaid
NJ014669C5WMedicare PIN
PAG77685Medicare PIN
NJ7624107Medicaid