Basic Information
| Provider Information | |||||||||
| NPI: | 1669563763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATHAWAY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 N BARTLETT ST | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541662127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155262111 | ||||||||
| FaxNumber: | 7155269174 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 N BARTLETT ST | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541662127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155262111 | ||||||||
| FaxNumber: | 7155269174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 36307 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 30064500 | 05 | WI | MEDICAID |