Provider Demographics
NPI:1609833938
Name:SHORTEN, SCOTT DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:SHORTEN
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 1:30701 LORAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-6325
Mailing Address - Country:US
Mailing Address - Phone:440-274-5000
Mailing Address - Fax:440-716-8608
Practice Address - Street 1:400 WABASH AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307
Practice Address - Country:US
Practice Address - Phone:330-344-2025
Practice Address - Fax:330-344-6418
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051934207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000028993OtherANTHEM BLUE CROSS BLUE SHIELD
OH0782890Medicaid
OH0782890Medicaid
F05889Medicare UPIN
000000028993OtherANTHEM BLUE CROSS BLUE SHIELD
OH0714431Medicare ID - Type Unspecified