Provider Demographics
NPI:1477765071
Name:KING, SCOTT J (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:KING
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:121 S SAINT LOUIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2924
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:611 E DOUGLAS RD STE 200
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1465
Practice Address - Country:US
Practice Address - Phone:574-272-5347
Practice Address - Fax:574-272-8617
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01070924A2085R0202X, 2085R0204X, 2085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201072620Medicaid
INM400071912Medicare PIN