Provider Demographics
NPI:1730152505
Name:SCOTT, STEPHEN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:SCOTT
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 1:17 VIRGINIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4406
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-784-4902
Practice Address - Street 1:43 JEFFERSON BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-1027
Practice Address - Country:US
Practice Address - Phone:401-941-2830
Practice Address - Fax:401-941-6886
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI09755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7000597Medicaid
RIG79430Medicare UPIN
RIG79430Medicare UPIN