Provider Demographics
NPI:1821142019
Name:ROSE, SCOTT WENDELL
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:WENDELL
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BROOK MILL LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8303
Mailing Address - Country:US
Mailing Address - Phone:314-576-9699
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-469-0760
Practice Address - Fax:314-469-0034
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO224541806Medicare PIN