Healthcare Provider Details

I. General information

NPI: 1215901046
Provider Name (Legal Business Name): JEFFREY SCOTT MCCOLLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S TEBO ST
WINDSOR MO
65360-1161
US

IV. Provider business mailing address

100 S TEBO ST
WINDSOR MO
65360-1161
US

V. Phone/Fax

Practice location:
  • Phone: 660-647-2147
  • Fax: 660-890-8496
Mailing address:
  • Phone: 660-647-2147
  • Fax: 660-890-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23869
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23869
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013030577
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: