Provider Demographics
NPI:1235263575
Name:SMITH, SCOTT BRYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5736
Mailing Address - Country:US
Mailing Address - Phone:573-334-0778
Mailing Address - Fax:573-334-0776
Practice Address - Street 1:2560 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5736
Practice Address - Country:US
Practice Address - Phone:573-334-0778
Practice Address - Fax:573-334-0776
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006598111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU71463Medicare UPIN
MO000031606Medicare PIN