Provider Demographics
NPI:1578598850
Name:SCOTT, MCKENNETH JR (PHYSICIANS ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MCKENNETH
Middle Name:
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W 168TH STREET PH 1-137
Mailing Address - Street 2:ASSOCIATES IN EMERGENCY SERVICES CLINIC
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3784
Mailing Address - Country:US
Mailing Address - Phone:212-305-2995
Mailing Address - Fax:212-305-6792
Practice Address - Street 1:622 W 168TH STREET PH 1-137
Practice Address - Street 2:COLUMBIA UNIVERSITY MED CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3784
Practice Address - Country:US
Practice Address - Phone:212-305-2995
Practice Address - Fax:212-305-6792
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:2006-07-19
Deactivation Code:
Reactivation Date:2006-11-16
Provider Licenses
StateLicense IDTaxonomies
NY006243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01903075Medicaid
S71631Medicare UPIN
NY01903075Medicaid