Provider Demographics
NPI:1881677714
Name:DIVENERE, SCOTT W (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:DIVENERE
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 1:2201 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5574
Mailing Address - Country:US
Mailing Address - Phone:815-725-1191
Mailing Address - Fax:815-725-2048
Practice Address - Street 1:2201 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5574
Practice Address - Country:US
Practice Address - Phone:815-725-1191
Practice Address - Fax:815-725-2048
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCH4890OtherRR MEDICARE
ILCH4890OtherRR MEDICARE
ILL78748Medicare ID - Type UnspecifiedWILL CO PROVIDER ID#
ILL92353Medicare ID - Type UnspecifiedGRUNDY CO PROVIDER ID#