Basic Information
| Provider Information | |||||||||
| NPI: | 1275604498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 S BRENTWOOD BLVD STE 550 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149774440 | ||||||||
| FaxNumber: | 3149771630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036103837 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 2017031136 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036103837002 | 05 | IL | MEDICAID |