Provider Demographics
NPI:1790731628
Name:POTTRATZ, SCOTT T (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:POTTRATZ
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 1:5629 HWY 21 S
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-9416
Mailing Address - Country:US
Mailing Address - Phone:912-295-2133
Mailing Address - Fax:
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-486-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036697207P00000X
GA072760207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100119850Medicaid
IN000000365696OtherBSIN
IN000000365696OtherBSIN
INE59637Medicare UPIN