Provider Demographics
NPI:1396711859
Name:BAMMANN, SCOTT A (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:BAMMANN
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 1:1245 15TH STREET N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1802
Mailing Address - Country:US
Mailing Address - Phone:320-253-5200
Mailing Address - Fax:320-203-2113
Practice Address - Street 1:1245 15TH STREET N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1802
Practice Address - Country:US
Practice Address - Phone:320-253-5200
Practice Address - Fax:320-203-2113
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN016708800Medicaid
MN016708800Medicaid
D48382Medicare UPIN