Provider Demographics
NPI:1992834162
Name:GRUPAS, SCOTT M (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:GRUPAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2847
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 SW ABBEY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4820
Practice Address - Country:US
Practice Address - Phone:541-265-2244
Practice Address - Fax:541-265-2244
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117312207P00000X
ORDO28619207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117312-4Medicaid
MO147480043Medicare PIN
ILPENDINGMedicare UPIN
MOIB1436037Medicare PIN