Provider Demographics
NPI:1669085544
Name:SCOTT STREET MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SCOTT STREET MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:570-693-6163
Mailing Address - Street 1:500 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-5616
Mailing Address - Country:US
Mailing Address - Phone:570-824-1700
Mailing Address - Fax:570-270-9060
Practice Address - Street 1:500 SCOTT ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5616
Practice Address - Country:US
Practice Address - Phone:570-824-1700
Practice Address - Fax:570-270-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty