Provider Demographics
NPI:1306232004
Name:GREMILLION, SCOTT DAVID (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:GREMILLION
Suffix:
Gender:M
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:980-442-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-02099390200000X, 207Q00000X
CT67291207Q00000X
SCMD52277207Q00000X
MA288544207Q00000X
OH35.144085207Q00000X
DCMD210001704207Q00000X
MA4950207Q00000X
NC209821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.144085OtherOHIO MEDICAL BOARD
NC209821OtherNC MEDICAL BOARD
NY307342OtherNY MEDICAL BOARD
CT67291OtherCT MEDICAL BOARD
SCMD52277OtherSC MEDICAL BOARD
DCMD210001704OtherDC MEDICAL BOARD
MA288544OtherMA MEDICAL BOARD