Provider Demographics
NPI:1386661742
Name:DELCOMYN, SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:DELCOMYN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:15400 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2333
Practice Address - Country:US
Practice Address - Phone:734-285-0100
Practice Address - Fax:734-285-0101
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-0-H2-2452-0OtherBCBS PIN
MI65-0-H2-2452-0OtherBCBS PIN