Provider Demographics
NPI:1639196272
Name:LANDRY, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:LANDRY
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 1:105 ERIC CRAIG CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7588
Mailing Address - Country:US
Mailing Address - Phone:636-477-4981
Mailing Address - Fax:
Practice Address - Street 1:10 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1659
Practice Address - Country:US
Practice Address - Phone:636-916-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000155010207P00000X
IL036-103851207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205361421Medicaid
MO205361405Medicaid
MO205361413Medicaid
MO962445005Medicare PIN
H28857Medicare UPIN
MO205361405Medicaid
MO025013209Medicare PIN
MO035013211Medicare PIN
MO034013210Medicare PIN
MO962445198Medicare PIN