Basic Information
| Provider Information | |||||||||
| NPI: | 1316938764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148385702 | ||||||||
| FaxNumber: | 3148395596 | ||||||||
| Practice Location | |||||||||
| Address1: | 637 DUNN RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | HAZELWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630421759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148385702 | ||||||||
| FaxNumber: | 3148395596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G57847 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | R9D52 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4000029 | 01 | MO | AETNA | OTHER | 127461 | 01 | MO | GHP | OTHER | 100161 | 01 | MO | HEALTHLINK | OTHER | 0400431 | 01 | MO | UHC | OTHER | 00000010007 | 01 | MO | ESSENCE | OTHER | 28771 | 01 | MO | BCBS | OTHER | A13912 | 01 | MO | MERCY | OTHER |