Provider Demographics
NPI:1336146703
Name:FILLMORE, SCOTT J (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:FILLMORE
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 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2203
Mailing Address - Fax:701-234-2899
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2203
Practice Address - Fax:701-234-2899
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9633225400000X
ND5962208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX979392OtherFOCUS
TX208100000XOtherPMR, SPECIALTY CODE
TX377226600OtherW/C
TX760420564OtherTAX ID
TX00H04COtherBC/BS OF TEXAS
TX123880501OtherMETHODIST CARE
TX541659OtherUSA MANAGED CARE ORG
TX033687701Medicaid
TX54349OtherHMO BLUE STAR PLUS
TX6800563003OtherCIGNA
ND14695Medicaid
TX250003082OtherRR MEDICARE
TX4511475OtherAETNA
TX813691OtherCIGNA
TX208100000XOtherPMR, SPECIALTY CODE
TX033687701Medicaid
MN250000821Medicare PIN
MN250000952Medicare PIN
TX760420564OtherTAX ID
TX123880501OtherMETHODIST CARE
TX813691OtherCIGNA