Provider Demographics
NPI:1013915792
Name:SCANLON, ROBERT CLAYTON II (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLAYTON
Last Name:SCANLON
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:1001 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5155
Practice Address - Country:US
Practice Address - Phone:417-875-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5F54208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19-40002OtherUHC PROVIDER ID
MO242280501Medicaid
333950115OtherMEDICARE PIN OCH
MO2075OtherGATEWAY EDI SUBMITTER ID
340006342OtherPALMETTO GBA-MRR ID
P00364221OtherMEDICARE RR OCH
MO10028OtherBC/BS PROVIDER ID
MO1013915792Medicaid
A10693Medicare UPIN
P00364221OtherMEDICARE RR OCH
333950115OtherMEDICARE PIN OCH