Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 05002042A | IN |
NPI | 1053497958 |
---|---|
Provider Name | Mr. Edward Lee Scott |
First Address | Lafayette, IN 47903-5545 |
Second Address | Lafayette, IN 47904-2479 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 15/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000528618 | ANTHEM PROVIDER NUMBER (01) | IN |
200896760 | (05) | IN |