Provider Demographics
NPI:1124094099
Name:SCOTT, ELISABETH (MD)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 SW MACADAM AVE
Mailing Address - Street 2:300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4152
Practice Address - Country:US
Practice Address - Phone:503-416-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-01525207Q00000X
ORMD154529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500635004Medicaid
H92212Medicare UPIN