Healthcare Provider Details

I. General information

NPI: 1144676511
Provider Name (Legal Business Name): SCOTT ERVIN MABRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL STE 6A/6B/12A
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8233
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-2551
  • Fax: 314-747-2598
Mailing address:
  • Phone: 314-514-3500
  • Fax: 314-514-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2021030412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: