Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD435019 | PA |
Y | 207Q00000X | Family Doctor | ME111202 | FL |
N | 207QS0010X | Family Doctor - Sports Medicine | MD.34630 | AL |
N | 207QS0010X | Family Doctor - Sports Medicine | ME111202 | FL |
NPI | 1326119462 |
---|---|
Provider Name | Scott Matthew Grayner |
First Address | Sweetwater, FL 33172-2746 |
Second Address | Delray Beach, FL 33446-1305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2006 |
Last Update Date | 07/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101167200 | (05) | FL |
KK175 | MEDICARE (01) | FL |