Provider Demographics
NPI:1508833773
Name:MANDERS, SCOTT
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:MANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 18TH ST
Mailing Address - Street 2:SUITE 512
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3231
Mailing Address - Country:US
Mailing Address - Phone:304-424-4574
Mailing Address - Fax:304-424-4429
Practice Address - Street 1:600 18TH ST
Practice Address - Street 2:SUITE 512
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3231
Practice Address - Country:US
Practice Address - Phone:304-424-4574
Practice Address - Fax:304-424-4429
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21542207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000320Medicaid
WV3810000320Medicaid
WV4131261Medicare ID - Type Unspecified