Healthcare Provider Details

I. General information

NPI: 1750300497
Provider Name (Legal Business Name): SCOTT T GRAHAM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 FORUM BLVD SUITE 104
COLUMBIA MO
65203-5404
US

IV. Provider business mailing address

3301 BERRYWOOD DR SUITE 204
COLUMBIA MO
65201-6517
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-5268
  • Fax: 573-442-5278
Mailing address:
  • Phone: 573-449-8771
  • Fax: 573-449-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2000174343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: