Provider Demographics
NPI:1396061776
Name:GEORGE C SCOTT MD
Entity type:Organization
Organization Name:GEORGE C SCOTT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-302-2506
Mailing Address - Street 1:1191 E YOSEMITE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5011
Mailing Address - Country:US
Mailing Address - Phone:209-239-4100
Mailing Address - Fax:209-239-4110
Practice Address - Street 1:1191 E YOSEMITE AVE
Practice Address - Street 2:STE C
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5011
Practice Address - Country:US
Practice Address - Phone:209-239-4100
Practice Address - Fax:209-239-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-11
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55402261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2176339Medicaid
CA00G554020Medicaid
CADD732AMedicare PIN
CA00G554020Medicaid
CAZZZ80852ZMedicare PIN