Provider Demographics
NPI:1932186939
Name:CROSS, SCOTT G (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:G
Last Name:CROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 115B
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4103
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-535-4130
Practice Address - Fax:208-535-4125
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7984207PE0005X
IDM-7984207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID58057OtherBLUE CROSS
ID805777500Medicaid
ID1144734Medicare ID - Type Unspecified
ID805777500Medicaid