Provider Demographics
NPI:1760480974
Name:EATHORNE, SCOTT WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:EATHORNE
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 1:15990 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:30055 NORTHWESTERN HWY
Practice Address - Street 2:#30
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3230
Practice Address - Country:US
Practice Address - Phone:248-865-4030
Practice Address - Fax:248-426-7335
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055302207QS0010X
MI4301056302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI297537810Medicaid
MIF38622Medicare UPIN
MI0F36020811Medicare ID - Type Unspecified