Provider Demographics
NPI:1801923180
Name:SCOT A. WALL, MD, PC
Entity type:Organization
Organization Name:SCOT A. WALL, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALL
Authorized Official - Suffix:X
Authorized Official - Credentials:MD
Authorized Official - Phone:229-888-2395
Mailing Address - Street 1:2308 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1324
Mailing Address - Country:US
Mailing Address - Phone:229-888-2395
Mailing Address - Fax:229-438-8345
Practice Address - Street 1:716 E 16TH AVE STE C
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-4517
Practice Address - Country:US
Practice Address - Phone:229-273-2395
Practice Address - Fax:229-273-2393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI4690Medicare PIN
GAGRP1833Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER