Healthcare Provider Details

I. General information

NPI: 1093332421
Provider Name (Legal Business Name): KEVIN G SCOTT MBA, RDCS, RVT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639A S WASHINGTON AVE
LEBANON MO
65536-3618
US

IV. Provider business mailing address

1700 S CAMPBELL AVE STE J
SPRINGFIELD MO
65807-2000
US

V. Phone/Fax

Practice location:
  • Phone: 417-209-3785
  • Fax: 833-792-4156
Mailing address:
  • Phone: 417-209-5700
  • Fax: 833-792-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number013648
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number013648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: