Provider Demographics
NPI:1760744916
Name:SCOTT, GRANT (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5155
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:417-875-3292
Practice Address - Street 1:3800 S NATIONAL AVE STE 400
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5272
Practice Address - Country:US
Practice Address - Phone:417-875-2632
Practice Address - Fax:417-875-3737
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZR73447208600000X
MO20190229042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200070649Medicaid