Basic Information
| Provider Information | |||||||||
| NPI: | 1154389856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAGELY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78009 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631788009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987142 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1252 COUNTY RD 8 | ||||||||
| Address2: | |||||||||
| City: | KEYSTONE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804350000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704686677 | ||||||||
| FaxNumber: | 9704687908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2008012510 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | L4589 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | DR.0041662 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 153533803 | 05 | TX | MEDICAID |