Provider Demographics
NPI:1790763571
Name:SCOTT, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:5404 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5332
Mailing Address - Country:US
Mailing Address - Phone:630-921-1606
Mailing Address - Fax:
Practice Address - Street 1:5404 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5332
Practice Address - Country:US
Practice Address - Phone:630-921-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100296207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100296Medicaid
IL036100296-4Medicaid
IL3932056OtherBLUE SHIELD
IL214881006Medicare PIN