Provider Demographics
NPI:1184656076
Name:SCOTT, KENNETH F JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:F
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 E GAINES DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-3205
Mailing Address - Country:US
Mailing Address - Phone:660-885-8141
Mailing Address - Fax:660-885-5815
Practice Address - Street 1:603 E GAINES DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-3205
Practice Address - Country:US
Practice Address - Phone:660-885-8141
Practice Address - Fax:660-885-5815
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34605207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C52058Medicare UPIN
MOH723215Medicare ID - Type Unspecified