Provider Demographics
NPI:1609828094
Name:PETHKE, SCOTT D (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:D
Last Name:PETHKE
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:NORTHSIDE HOSPITAL MANAGED CARE DEPARTMENT
Mailing Address - Street 2:1000 JOHNSON FERRY RD NE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350
Mailing Address - Country:US
Mailing Address - Phone:404-300-2476
Mailing Address - Fax:404-250-8010
Practice Address - Street 1:1301 BROAD ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1055
Practice Address - Country:US
Practice Address - Phone:706-922-5864
Practice Address - Fax:706-922-5819
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066307207RP1001X
LA10684R207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5808779OtherAETNA
LA1492582Medicaid
LA4800148OtherUNITED HEALTHCARE
LA1492582Medicaid
LA1492582Medicaid