Provider Demographics
NPI:1093211765
Name:SORGE, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SORGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:082-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-302-4200
Practice Address - Fax:208-302-4255
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-19692084N0400X
ORDO2107082084A2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program