Provider Demographics
NPI:1255405023
Name:MOOSE, SCOTT R (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:MOOSE
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:940 W MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-9609
Practice Address - Country:US
Practice Address - Phone:417-724-5200
Practice Address - Fax:417-724-5203
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209747302Medicaid
MO244013268Medicare PIN
MO209747302Medicaid
MO294013268Medicare PIN
MO004013230Medicare PIN