Provider Demographics
NPI:1649233271
Name:SCOTT, JERRY W (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:SCOTT
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 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1100
Mailing Address - Fax:304-691-1183
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 1500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1100
Practice Address - Fax:304-691-1183
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV18844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0054893000Medicaid
KY64025398Medicaid
OH2209550Medicaid
WVG53221Medicare UPIN
WV0826285Medicare PIN