Provider Demographics
NPI:1013344290
Name:PARKS, SCOTT DANIEL
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DANIEL
Last Name:PARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10078 LAPEER RD
Practice Address - Street 2:STE B
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-9031
Practice Address - Country:US
Practice Address - Phone:810-653-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211122Medicare PIN
MIN69750071Medicare PIN