Provider Demographics
NPI:1275604498
Name:WONG, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:WONG
Suffix:
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 1:6810 STATE ROUTE 162 STE 100
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8560
Mailing Address - Country:US
Mailing Address - Phone:618-288-3616
Mailing Address - Fax:618-288-3647
Practice Address - Street 1:6810 STATE ROUTE 162 STE 100
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8560
Practice Address - Country:US
Practice Address - Phone:618-288-3616
Practice Address - Fax:618-288-3647
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017031136208600000X
IL0361038372086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103837002Medicaid
ILK11629Medicare PIN