Provider Demographics
NPI:1154397149
Name:ANDERSON, SCOTT MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14825 E 560 ROAD
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036
Mailing Address - Country:US
Mailing Address - Phone:918-543-6596
Mailing Address - Fax:
Practice Address - Street 1:1934 S HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019
Practice Address - Country:US
Practice Address - Phone:918-283-2527
Practice Address - Fax:918-283-2569
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
376624Medicare ID - Type Unspecified