Healthcare Provider Details

I. General information

NPI: 1508033960
Provider Name (Legal Business Name): SCOTT ROBERT UNDERWOOD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 SUNSET BLVD SUITE 200
O FALLON IL
62269-1960
US

IV. Provider business mailing address

787 SUNSET BLVD SUITE 200
O FALLON IL
62269-1960
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-2400
  • Fax: 618-624-2407
Mailing address:
  • Phone: 618-624-2400
  • Fax: 618-624-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011164
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: