Basic Information
Provider Information | |||||||||
NPI: | 1215970488 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCIPIONE | ||||||||
FirstName: | KENDRA | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7080 SW PALMER WAY | ||||||||
Address2: |   | ||||||||
City: | BEAVERTON | ||||||||
State: | OR | ||||||||
PostalCode: | 970075153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004243672 | ||||||||
FaxNumber: | 9543773042 | ||||||||
Practice Location | |||||||||
Address1: | 3501 JOHNSON ST | ||||||||
Address2: |   | ||||||||
City: | HOLLYWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 330215421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549872000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 02/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME67213 | FL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD175666 | OR | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 26785 | 01 | FL | BLUE SHIELD OF FL | OTHER | 377962900 | 05 | FL |   | MEDICAID | MD175666 | 01 | OR | OREGON MEDICAL LICENSE | OTHER |