Provider Demographics
NPI:1366439721
Name:BOERTH, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BOERTH
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 1:2000 HEALTH PARK DR FL HP2
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:3698 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7015
Practice Address - Country:US
Practice Address - Phone:540-951-6070
Practice Address - Fax:540-951-6071
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1366439721Medicaid
VA005846129Medicaid
VA010287910Medicaid
VA1366439721Medicaid
VA010287910Medicaid
VAVV0635AMedicare PIN
VA005846129Medicaid
VAP00912977Medicare PIN
VAH16505Medicare UPIN