Provider Demographics
NPI:1508033960
Name:UNDERWOOD, SCOTT ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERT
Last Name:UNDERWOOD
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 1:787 SUNSET BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1960
Mailing Address - Country:US
Mailing Address - Phone:618-624-2400
Mailing Address - Fax:618-624-2407
Practice Address - Street 1:787 SUNSET BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1960
Practice Address - Country:US
Practice Address - Phone:618-624-2400
Practice Address - Fax:618-624-2407
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011164111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor