Healthcare Provider Details

I. General information

NPI: 1730315326
Provider Name (Legal Business Name): SCOTT COLOGNE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 CRAIG RD STE 101
SAINT LOUIS MO
63141-7175
US

IV. Provider business mailing address

PO BOX 23478
SAN DIEGO CA
92193-3478
US

V. Phone/Fax

Practice location:
  • Phone: 402-672-2163
  • Fax:
Mailing address:
  • Phone: 402-672-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2006005276
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number2006005276
License Number StateMO

VIII. Authorized Official

Name: SCOTT COLOGNE
Title or Position: OWNER/SOLE MEMBER
Credential: MD
Phone: 402-672-2163