Provider Demographics
NPI:1750300497
Name:GRAHAM, SCOTT T (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:2902 FORUM BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5404
Practice Address - Country:US
Practice Address - Phone:573-442-5268
Practice Address - Fax:573-442-5278
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOL35000021Medicare PIN
MO000025273Medicare ID - Type Unspecified