Provider Demographics
NPI:1972715977
Name:GRAND BLANC OBSTETRICS & GYNECOLOGY PC
Entity Type:Organization
Organization Name:GRAND BLANC OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-694-7095
Mailing Address - Street 1:8423 HOLLY RD
Mailing Address - Street 2:STE B
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2487
Mailing Address - Country:US
Mailing Address - Phone:810-694-7095
Mailing Address - Fax:810-694-7224
Practice Address - Street 1:8423 HOLLY RD
Practice Address - Street 2:STE B
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2487
Practice Address - Country:US
Practice Address - Phone:810-694-7095
Practice Address - Fax:810-694-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075129207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N65890Medicare PIN