Provider Demographics
NPI:1023420361
Name:SCOGGIN, ELISE (DO)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:SCOGGIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-1200
Mailing Address - Fax:217-277-3960
Practice Address - Street 1:1132 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2819
Practice Address - Country:US
Practice Address - Phone:217-214-6250
Practice Address - Fax:217-385-3850
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036146947207N00000X
PAOT015672207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology