Provider Demographics
NPI:1811257462
Name:BLACK, SCOTT BAYLES (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:BAYLES
Last Name:BLACK
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:PO BOX 3300
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-3300
Mailing Address - Country:US
Mailing Address - Phone:541-536-3435
Mailing Address - Fax:
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-8887
Practice Address - Country:US
Practice Address - Phone:541-536-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8699736-1205207Q00000X
ORMD171322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine