Provider Demographics
NPI:1659344554
Name:SCOTT, KENNETH A (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12150 30 MILE RD
Mailing Address - Street 2:STE 105
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2035
Mailing Address - Country:US
Mailing Address - Phone:586-336-7333
Mailing Address - Fax:586-336-7332
Practice Address - Street 1:12150 30 MILE RD
Practice Address - Street 2:STE 105
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2035
Practice Address - Country:US
Practice Address - Phone:586-336-7333
Practice Address - Fax:586-336-7332
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIKS013195207X00000X
MI5101013195207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4198242Medicaid
MI25628Medicare UPIN
MI4198242Medicaid