Provider Demographics
NPI:1871676163
Name:SCOTT, KEVIN C (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
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 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:067-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085671208800000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI34-0-22-1066-2OtherBLUE CROSS BLUE SHIELD
MI4763830Medicaid
MI4940774Medicaid
MI4763830Medicaid
MIP17000004Medicare ID - Type Unspecified
MI0B26002122Medicare PIN
MI4940774Medicaid