Basic Information
| Provider Information | |||||||||
| NPI: | 1609833938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORTEN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30701 LORAIN RD STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WABASH AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303442025 | ||||||||
| FaxNumber: | 3303446418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35051934 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000028993 | 01 | ANTHEM BLUE CROSS BLUE SHIELD | OTHER | 0782890 | 05 | OH | MEDICAID |