Provider Demographics
NPI:1154302677
Name:ANDERSON, SCOTT A (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2444
Mailing Address - Country:US
Mailing Address - Phone:573-632-4800
Mailing Address - Fax:573-632-4890
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2444
Practice Address - Country:US
Practice Address - Phone:573-632-4800
Practice Address - Fax:573-632-4890
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G43207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243615317Medicaid
IA1154302677Medicaid
MO311535384Medicare PIN
MOE23586Medicare UPIN
MOMA1379003Medicare PIN