Provider Demographics
NPI:1770623811
Name:ROSCOE, PETER JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:STE C55
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2386
Mailing Address - Country:US
Mailing Address - Phone:314-542-2205
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD STE C55
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2386
Practice Address - Country:US
Practice Address - Phone:314-989-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001020193111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor