Provider Demographics
NPI:1699989301
Name:SCOTT BEALS DO PA
Entity type:Organization
Organization Name:SCOTT BEALS DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEALS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-897-7546
Mailing Address - Street 1:4566 E HIGHWAY 20
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8838
Mailing Address - Country:US
Mailing Address - Phone:850-897-7546
Mailing Address - Fax:850-897-7547
Practice Address - Street 1:4566 E HIGHWAY 20
Practice Address - Street 2:SUITE 101
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8838
Practice Address - Country:US
Practice Address - Phone:850-897-7546
Practice Address - Fax:850-897-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7143207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13586YOtherFLORIDA MEDICARE PTAN INDIVIDUAL #
FL266706100Medicaid
FLK4270OtherFLORIDA MEDICARE PTAN GROUP #
FL266706100Medicaid