Provider Demographics
NPI:1336328137
Name:W SCOTT SUPPLEE MD PA
Entity Type:Organization
Organization Name:W SCOTT SUPPLEE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SUPPLEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:410-821-7676
Mailing Address - Street 1:6569 N CHARLES ST
Mailing Address - Street 2:STE 610
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6831
Mailing Address - Country:US
Mailing Address - Phone:410-821-7676
Mailing Address - Fax:410-825-7205
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:STE 610
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:410-821-7676
Practice Address - Fax:410-825-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38840207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK435Medicare PIN