Provider Demographics
NPI:1144853433
Name:SCOTT J DAVIDSON
Entity type:Organization
Organization Name:SCOTT J DAVIDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-751-5429
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-0871
Mailing Address - Country:US
Mailing Address - Phone:207-751-5429
Mailing Address - Fax:
Practice Address - Street 1:9 EVERETT ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2403
Practice Address - Country:US
Practice Address - Phone:207-751-5429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTT J DAVIDSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME135350000Medicaid