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General NPI Number Information
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NPI Number | 1184679961
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Entity Type | Individual
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Provider Name | SCOTT P WASSERSTROM MD
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Gender | Male
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 04/18/2025
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Provider Practice Location Address
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Address Line | 1110 HIGHLANDS PLAZA DR E STE 375
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City | SAINT LOUIS
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State | MO
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Zip | 63110-1392
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Country | US
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Telephone | 314-367-3113
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Fax | 314-454-9382
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Provider Business Mailing Address
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Address Line | PO BOX 7412035
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City | CHICAGO
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State | IL
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Zip | 60674-2035
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Country | US
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Telephone | 314-367-3113
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Fax | 314-454-9382
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 108667
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License Number State | MO
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